... walks like a duck, and quacks liks a duck, it may not be a duck.

A 56 year old male patient, moderately overweight, presented to the ED with all the classic symptoms of an acute MI (myocardial infarction, AKA a heart attack). He was diaphoretic, short of breath, hypertensive, tachycardic, and complaining of chest pain which felt like "someone was sitting on his chest". The pain was radiating to his jaw and down his arm.

All the classic flags for an acute MI went up and we quickly begun to work him up as such. We inserted a saline lock, drew cardiac enzymes and other labs, put him on 2 liters of oxygen via nasal cannula, got an EKG, chest X-ray, etc etc - the standard protocols. The patient was in too much distress to speak or give us a history and didn't have anyone with him since he had driven himself to the ED.

The EKG was definitely positive for an ST elevation acute MI and we started making the calls to cardiology, cath lab, etc. As we were doing all this, I went over to the bedside and started to talk to him, telling him what was happening. He begun to gesture frantically when he heard the words "cardiac cath", and he was desperately trying to tell me something. He was so agitated that he was hyperventilating. I got the doc to come in, and we tried to calm him down, and finally he was able to speak to us and tell us that he didn't need the cath lab, he wasn't having an MI, he was having an episode associated with Tako-tsubo syndrome, a rare syndrome that mimics an acute MI.

I didn't have the opportunity to follow his case since we were at shift change by that point, but here's some interesting stuff I learnt:

Tako-tsubo Cardiomyopathy or Syndrome is also known as: neurogenic myocardial stunning, stress cardiomyopathy, stress-induced cardiomyopathy, transient left ventricular apical ballooning, "ampulla" cardiomyopathy, or "broken heart syndrome" (because it if often precipitated by an emotional stressor such as the death of a loved one). It presents clinically with all the symptomatology of an acute MI. During an attack, a bulging out of the left ventricular apex with a hypercontractile base of the left ventricle is often noted. It is this hallmark bulging out of the apex of the heart with preserved function of the base that earned the syndrome its name "tako tsubo", or octopus trap in Japan, where it was first described. It is precipitated by severe emotional stress which causes an overabundance of catecholamines in the system. There is no vessel blockage to explain the ventricular dysfunction, and with supportive measures the ventricular function is often restored in two months.

You can read more about Tako-tsubo syndrome in layman's terms at http://www.takotsubo.com/.

More reading:
http://www.medscape.com/viewarticle/521107_2
http://en.wikipedia.org/wiki/Takotsubo_cardiomyopathy

A duck is occasionally not always a duck.