Chest Pain Equivalent
She was 40 years old, a working mother, a few years post hysterectomy for menorrhagia (heavy periods) but otherwise healthy. She didn't drink or smoke, and she had no family history of coronary artery disease. She took no medications, and although she didn't have a regular physician, she admitted that on a recent life insurance screening her cholesterol was reported as a bit high.
She'd had a stressful week at work as well as at home with the kids, who were just starting school. While driving home one afternoon her left shoulder began to ache, and the pain seemed to radiate down her left arm. Funny, she'd never had that before. Her arm started to go a bit numb as well, and she began to get a little anxious, maybe even short of breath. She didn't have any chest pain whatsoever. Her symptoms lasted about an hour, but then recurred later that evening, so she asked her husband to drive her to the ER.
Her blood pressure was 170/90, heart rate 80, respirations normal and unlabored. Her heart, lung, and abdominal examinations were normal, and her examination of the upper extremities did not reveal any reproducible pain on palpation or movement. There was no peripheral edema or calf tenderness, and her distal pulses were normal.
Her ECG was entirely normal, as were her chest X-ray and laboratory studies, including cardiac enzymes. She had no pain in the emergency department. It had been five hours since the symptoms began. I gave her an aspirin and some IV Lopressor, and called to get her admitted for observation and workup.
The physician on call for the hospital gave me a bit of unexpected resistance. "What do you mean, chest pain equivalent? Does she have chest pain or not?"
Well, I explained, these symptoms could absolutely be consistent with the new onset of resting angina, thus "unstable" by definition. The tests we have done so far are not sufficient to rule that out. Women in particular tend to have more atypical presentations of heart disease. This could be a warning sign of a heart attack about to happen.
"But she's only 40! And she has no risk factors. I just can't justify admitting her," the physician said abruptly.
The fact that she's only 40 worries me more than anything, I said. This is an employed mother of two with a 40+ year life expectancy. With the new tort reform laws in Texas, noneconomic damages in malpractice cases are limited to $250,000. This essentially means that only the most egregious cases or those involving large amounts of lost income are filed these days. Besides, she does have the risk factors of surgical menopause, reportedly high cholesterol, and untreated hypertension. Anyway, if it is her heart acting up then this is potentially life-threatening. She needs to be admitted. You can't justify NOT admitting her, in my book. If we have to admit a hundred patients like her to avoid missing one heart attack, then I think it is reasonable to do so. That is exactly why we have a chest pain observation unit.
He grudgingly agreed to admit the patient, and I moved on to the other patients in the ER.
Labels: patients
posted by scalpel at 12:45 AM
7 Comments:
I have been in practice for four years. I have greater then ten patients in my practice under the age of forty with major MI's or CABG. Anyone who tells you forty is to young for coronary disease shouldn't be practicing!
And she has no risk factors
Guess he didn't think that HTN or hyperlipidemia were risk factors.
My clinical experience is similar to Jordan's - have many patients who had their first MIs before 40 (none female), and have seen a few females with MIs by 50 (and I work in the VA where the population is >90% male).
Based on my experience, many patients, not just women, have "atypical" CP sx and not classic anginal sx.
CardioNP
Absolutely you are both correct. Atypical symptoms occur as often as typical ones.
A middle-aged patient who had recently been discharged after an extensive GI evaluation came in with upper abdominal pain and vomiting. We were so busy, he sat on a stretcher in the hall for a couple of hours before we could get him into a room. After I examined him, noting his tenderness in the epigastrium and RUQ, I was trying to decide whether to order a CT scan or ultrasound, and I asked for an ECG while I wrote my note .
Big ST elevation MI! He had never had an ECG during his last hospitalization despite an upper endoscopy, CT, and U/S. He had no chest pain, but these were the same symptoms that he had been having.
Another time, a 50 year old VIP came in and was seen immediately by the trauma director of our large academic ER. He had left arm pain but no chest pain, like the patient in the original post. Neurosurgery was consulted immediately and diagnosed a radiculopathy, arranged for an MRI with outpatient followup, but no ECG was done. He came back a week later with worsening of the same left arm pain, this time he saw a regular ER doc who ordered an ECG which showed huge ST elevation tombstones, and the patient went directly to the cath lab.
Good thing there are some docs who will stand their ground and watch out for the rest of us.
Sounds pretty weak but that sixth sense has saved me and a patient many times. I can't argue all these low risk ones for admission every day because you see 4-5 of them a shift. There are not enough hospital beds in the world for that. If no other alternative I will keep them in the ER, do a second set of enzymes, and do a cheap mans treadmill at the bedside.
Las week I did have a 34 y/o woman with no risk factors having an ST segment elevation MI. Symptoms were very typical however as they are when CAD occurs in young people. It would have been a very tough sell to the cardiologist had she not been to the ER two days before for chest pain that had resolved and had a normal EKG that could be compared to.
Anon: Admittedly, I can't say that I have admitted every 40 year old with nonspecific symptoms and negative studies, so perhaps there is a bit of sixth sense in play. Often I will just present the statistics and let the patient decide how much risk they want to take.
The repeat ECG prior to discharge has saved me more than once, as has the "just in case" troponin.
I've seen a 35 year old man have a heart attack 3 days after a normal exercise stres test, and a 50 year old woman die from an acute MI who had a completely normal heart cath 6 months prior, and her autopsy showed a new 95% LAD lesion. The 10 year cardiac mortality in a patient with normal coronary arteries by cath is 0.1%.
The longer we practice, the more 1/1000 and 1/1,000,000 cases we see, and that perhaps unreasonably introduces some statistical bias.
There was an interesting piece a while ago in the NYT about a woman who had been diagnosed with functional cardiac pain - primarily because she was young with no obvious risk factors. To cut a long story short, she was an example of someone with microvascular disease.
Regards - Shinga
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