Detecting a heart attack

A plot point of a book I am reading involves faking a heart attack. A older man in poor physical condition takes cocaine to elevate his heart rate and make himself sweaty and flushed. According to the characters, this fooled the hospital into thinking he had a heart attack. Dangerous, the narration wanton, because there was a chance this could have triggered a real heart attack.

My understanding in real life is that confirming a heart attack is pretty foolproof, and involves checking for the presence of certain proteins in the blood. Cocaine symptoms would never be mistaken for a heart attack at the hospital.

Am I right? Or did Dennis Lehane do more research than I give him credit for?

Well, it depends if the diagnosis was a tentative ‘clinical’ one (based on the history and physical) or the ‘final’ diagnosis (which is based on all available information, including, in the case of heart attacks, an ECG and the blood levels of those proteins you mentioned).

That being said, the official diagnostic criteria for a heart attack (used, for example, in diagnostic coding for billing and research purposes) is the presence of any two of following three things:

  1. typical chest pain (angina) for at least 20 minutes
  2. ECG changes of a heart attack
  3. cardiac enzyme rise in the blood (those proteins)

Cite for the above definition.

So, a heart attack can be diagnosed without cardiac enzyme (protein) levels rising.

An EKG/ECG will discriminate between simple tachycardia and an arrhythmia associated with a myocardial infarct posthaste

And apparently, a heart attack changes your ECG (damn if I can figure why it’s also called an EKG) in ways that can be seen long after the event.

I got a more-or-less routine ECG once. The computer-generated analysis said I had an infarction. The doctor told me that this could have been some time in the past (I didn’t get whether that might mean recent past or long-time past), and that it could be some minor thing, and I shouldn’t worry about it. Certainly, I’m not aware of ever having had a heart attack. And I’m wondering if that sort of reading could have a tendency toward false positives.

I had a similar situation with a brain tumor. If it’s not causing you symptoms, it’s minor. I believe that’s a major diagnostic criteria for mental illness too: if it’s not causing a disruption in your daily life, it’s minor and doesn’t need to be treated.

So the guy largely credited with coming up with the EKG is William Einthoven, who was Dutch. Being Dutch, he called it the elektrokardiogramm, hence EKG. Also, ECG sounds more like EEG (electroencephalography), which can lead to confusion and woe.

Cite: Rapid Interpretation of EKGs. (I have the actual book, the bit about EKG vs ECG is not in the Wiki link.)
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With tools available in the ER? There are protocols that are in use that are pretty reliable but foolproof is going a bit far.

Yup. These proteins are usually elevated with MIs. They can also be elevated in cocaine users, marathon runners, people with rheumatoid, and a host of other conditions, so its far from perfect, especially if only a single data point is used.

“Cocaine chest pain” is an actual diagnosis and it’s not always easy to differentiate it from an MI, at least not immediately. Ruling out a heart attack often takes several hours and serial blood draws.

Meh. If someone walks in complaining of chest pain and is tachycardic they’ll get the usual workup to rule out a heart attack. Assuming no one checks his urine and his blood work comes back a little high, which is certainly possible, he’d probably be told he had a minor heart attack. Doesn’t seem terribly implausible.

:dubious: This is totally false.

I’ll state without a cite (since no one seems to read what I post anyway) that about one in three heart attacks are “silent” (no pain, no recollection of pain).

Okay, fine, here’s one reference (of many).

What’s the plot point? Being admitted for 23 hour observation can be based on as little as a good story without any hard diagnostic points. Docs vary on how conservative they treat someone of a certain age, who says all the right things. Is your subject trying to establish an alibi, or run an insurance fraud?

I’m just curious as to why he wanted to do this. When already in a hospital? Or to get admitted to hospital?

It would seem a risky act, because one would think that while trying to determine the cause of symptoms like this, they might do some kind of drug screening tests on the blood.

OTOH, simply having a positive tox screen is rarely, if ever, a crime in and of itself.

Well, I wasn’t talking about being charged with a crime necessarily. But depending on what the scheme is, finding out that it wasn’t a heart attack could spoil it… maybe.

When my ex had a heart attack, I had him in the ER in under 8 minutes from his waking with chest pain. Even while they were treating him for an MI (morphine, aspirin, oxygen, nitroglycerin and maybe some beta blockers) the doc kept saying “I think this is gastric” because his EKG looked good. His cardiac enzymes hadn’t had time to rise yet. I kept saying, no it’s cardiac. Finally a few hours later his cardiac enzymes rose and he got shipped out to a Nashville hospital for a stent. He had a Non ST(segment) Elevated MI (NSTEMI)

How did you get him to the ER in 8 minutes? Does it involve time-compression achieved by driving at near-light speed?


He’s a crooked cop involved in dropping off the money to satisfy a ransom demand. The supposed kidnappers demand that the ransom be brought through the woods to a quarry. (Hope Snowboarder Bo doesn’t read this). He fakes a heart attack and the rest of the group that is supposed to deliver the money goes on ahead. But he had switched the money out, and carries the real package away and hides it, then stumbles back down the mountain and is airlifted to the hospital. Where the doctors “confirm” his heart attack, giving him perfect cover.

Because electrocardiography was developed at around the same time electroencephlography was developed. ecg and eeg were (supposedly) confusing, because they looked too alike in doctors’ handwriting.

At least, that’s what I was told in my history of medicine class 100 years ago.

Nope, it is from the German “ElektroKardioGramm”.

LOL, no, we just threw on some clothes and got in the car. I lived about a mile from the hospital, but I did hit 65 mph before I got there (country road, gotta watch for deer.) I only know the time because I looked at the digital clock when he woke me, and checked it against the timestamp when I called my work to tell them I wouldn’t be in the next morning. 8 minutes, and way faster than the ambulance could have gotten to us. My only fear was what to do if he passed out before I could get him in the door.