Clinical Geriatrics

Case Presentation

A 77-year-old woman lost consciousness while stepping out of an automobile. She had previously been feeling well and had been playing cards earlier in the day with friends. She quickly became alert, but while awaiting the ambulance and during the ambulance ride to the hospital, she developed recurrent syncope. Heart rates in the 20s to 30s were recorded and were unresponsive to atropine and epinephrine. Brady-arrhythmia persisted in the emergency room, associated with nausea and vomiting. The patient was intubated. She had no signs of congestive heart failure on examination or chest x-ray. An electrocardiogram showed normal sinus rhythm with complete heart block and left bundle branch block.

External pacing was applied, and the patient was transferred to a tertiary care center. A temporary pacemaker was subsequently inserted. She was noted to have periods of normal sinus rhythm with a right bundle branch block and left anterior fascicular block. She used her pacemaker intermittently overnight.  

The patient had a long history of non–insulin-dependent diabetes mellitus, hypertension, and hyperlipidemia. Over the previous 6 months she had noted an uncomfortable pulsing sensation in her throat, often accompanied by transient disequilibrium and lightheadedness. She attributed the symptoms to possible gastroesophageal reflux and did not seek medical attention. She had a similar sensation the day of admission preceding her syncopal event. She denied any history of chest pain but had noted unusual fatigue over the previous month.  

On the morning following admission she was able to be extubated. An echocardiogram demonstrated moderately reduced left ventricular function and septal wall hypokinesis. Troponin peaked at 6, and a cardiac catheterization was performed. She was noted to have a relatively small, diffusely diseased vessel with a high-grade stenosis of the mid left anterior descending artery. A stent was successfully deployed (Figure). She was placed on intravenous glycoprotein IIb/IIIa inhibitor overnight. Postprocedural course was uncomplicated. The pacemaker was removed and no further heart block was noted as beta-blocker therapy was instituted.  

Due to the history of alternating right and left bundle branch block in the setting of syncope, infranodal conduction disease was suspected, and a permanent pacemaker was inserted.

Discussion

Coronary vascular disease is the leading cause of death among women in the United States, although its significance is clearly underrecognized by the female population. Nearly two in three women will die of coronary artery disease (CAD). Accurate diagnosis of CAD in women has been challenging due to the high prevalence of atypical presentations and lack of suspicion by both women and their doctors. This case illustrates many of the features of acute coronary syndrome in women. Ignoring symptoms or failing to seek medical attention often occurs in the elderly female population. Symptoms can go unrecognized because women often do not experience classic anginal chest pain (Table).

Chest pain, the hallmark of coronary ischemia, was reported as a prodromal symptom during 1 month prior to acute myocardial infarction (MI) in only 30% of women retrospectively studied in a recent large cohort of patients.1 Only slightly more than half the patients experienced chest pain at the time of the acute MI. The most frequent prodromal symptoms were fatigue, sleep disturbance, shortness of breath, and indigestion, whereas the most frequent acute symptoms included shortness of breath, weakness, and unusual fatigue. When chest pain does occur, it is not always the classic pressure-like sensation, but descriptors such as burning, fullness, tightness, and tingling are often used by women. Women are also more significantly likely to present with upper abdominal pain, dyspnea, and nausea as primary complaints during an acute coronary event.