I’ve been on call this week and it’s been rather busy, particularly this weekend, and particularly with patients presenting to hospital with chest pain. Such patients usually have a blood test called a ‘troponin’, which is a blood enzyme which gets elevated in the context of any heart damage or inflammation. As such, we use it to help make a diagnosis of a heart attack (as opposed to angina where there is no evidence of heart damage).
However, not all ‘heart attacks’ are the same…
One young man in his 30s I was asked to consult on presented a bit of a diagnostic conundrum. His symptoms of chest pain were not quite typical of a heart attack, and whilst I do sometimes see patients as young as this with coronary disease usually they are overweight, diabetic, smokers, have a family history or raised cholesterol, or a combination. This man had none of those risk factors. His ECG (paper tracing of the heart) was normal.
The odd thing was, his troponin blood test was raised.
He had had a recent upper respiratory tract infection, which sounded viral but not particularly severe. That raised the possibility of the diagnosis myocarditis, or inflammation of the heart. It didn’t really fit either as a diagnosis, but in the absence of a better explanation that was going to be my working diagnosis. I explained this to the man, and outlined what the plan was. However I was all set to move on to the next patient when he said ‘oh one more thing i should mention just in case….’
He had had a rather blocked up nose with his cold, and had been using an over the counter nasal spray to ease his congestion symptoms.However it turns out that although the recommended dose on the bottle was to use a couple of sprays twice a day, he had used many many more than that as his nose had felt so blocked.
I have seen this once before a few years ago and as it was unusual, it stuck in my mind. These drugs work by causing vasoconstriction, or a tightening of the blood vessels in the nose. However in excess, it can cause more widespread vasoconstriction, and can precipitate a heart attack. I think this is exactly what happened here. Fortunately a heart scan showed no damage, and after 24 hours observation I was able to discharge him today.
I think this serves as a great reminder to always check the label on any medication, particularly over the counter drugs, and stick to recommended doses. It’s also a great reminder on how important history taking is medicine. Whilst common diagnoses are common, it certainly makes my life interesting to see unusual cases like this every now and again!