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.