Correspondence: ‘You look dishevelled’ – MI in a cardiologist diagnosed by his secretary

Correspondence from the world of cardiology

Dear Sirs,

A few months ago, I arrived in the cardiology office around midday on Monday after a short ward round. One of our secretaries voiced the view “You don’t look right”. I was surprised when she qualified this as “looking dishevelled”. When asked what she meant, she was instantly apologetic and said “Oh I mean you look wide-eyed and agitated”.

The background was that I had felt nauseous whilst driving the car early Saturday afternoon and had, in fact, stopped the car to vomit on three occasions. I assumed I had eaten something that had upset me. The following day (Sunday) I continued doing minor jobs around the house and on the Monday went to work when the aforesaid conversation took place. Having previously arranged to check a PSA (prostrate-specific-antigen) level on myself, a cardiology colleague suggested I add a troponin to this blood request.

Blood taken, I drove home and received a phone call to tell me my troponin-I had come back at 1,800 ng/L (normal range 0–40 ng/L). Feeling perfectly well and having experienced no discomfort at any time, I then drove to my local tertiary centre to undergo coronary angiography. This showed unobstructed coronary arteries. A cardiac MRI scan confirmed an apical left ventricular infarct. There followed further discussion and investigations concerning the possibility of a paradoxical embolic event, which remained unproven.

Whilst I had experienced no discomfort, I had been suffering anxiety due to a lack of junior staff support. This had manifested as me waking in the night and ruminating about who might appear for the team in the morning. After 32 years of clinical practice, the ‘lack of any consistency in team support’ was a far bigger concern than any clinical issues arising amongst my patients. I can only conclude this event was precipitated by stress, in much the same way as the condition Takutsubo syndrome (a usually reversible cardiomyopathy most frequently seen in middle-aged women who have experienced psychosocial trauma).

The overriding messages seem to be that your facial appearance often helps in diagnosing cardiac events. As a cardiologist and well aware of a ‘cardiac face,’ how could I have missed this in myself? And how many have such an event without ever being aware?