Fitting a Square Peg in a Round Hole: A Simple Case of Chest Pain

Mary Mclean,Jennifer Beck-Esmay

doi:10.5811/cpcem.2019.10.44141

Abstract

A 39-year-old female presents to the emergency department with chest pain and shortness of breath. Her electrocardiogram suggests ST-elevation myocardial infarction, but she has no atherosclerotic risk factors. She is gravida 4, para 4, and four weeks postpartum from uncomplicated vaginal delivery. She is diaphoretic and anxious, but otherwise her exam is unremarkable. Cardiac enzymes are markedly elevated and point-of-care echocardiogram shows inferolateral hypokinesis and ejection fraction of 50%. In this clinicopathological case, we explore a classically underappreciated cause of acute coronary syndrome in healthy young women.

Highlights

A 39-year-old female presents to the emergency department with chest pain and shortness of breath
Spontaneous coronary artery dissection (SCAD) is defined as “separation of the coronary arterial wall by intramural hemorrhage creating a false lumen, with or without an intimal tear.”[10]. It develops in much the same way as aortic dissection; an intimal tear often results in high-pressure accumulation of hematoma between the vessel layers
The vasa vasorum can bleed between weakened vessel layers to create intramural hematoma

Summary

Clinicopathological Case

A 39-year-old female presents to the emergency department with chest pain and shortness of breath Her electrocardiogram suggests ST-elevation myocardial infarction, but she has no atherosclerotic risk factors. The patient is a 39-year-old female with 10/10 crushing left chest pain radiating to the left arm Her field electrocardiogram (ECG) is suggestive of inferior ST-elevation myocardial infarction (STEMI). Stable and she received nitroglycerin and aspirin, but ECG showed persistent inferior ST elevation and reciprocal changes At this point, the case seems quite simple: the STEMI code should have been activated, and the patient should have had immediate coronary angiography. Let’s step back and review the most significant details This patient was a previously healthy 39-year-old female, whose chest pain presentation was complicated by the fact that she was G4P4 and just four weeks postpartum.

Specific gravity

Value Negative Negative Negative Negative Negative

Findings

RESIDENT DISCUSSION Pathophysiology