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SAEM Clinical Image Series: A Young Woman with Chest Pain

ECG

A 35-year-old female with a history of intermittent palpitations who is three months post-partum presented to the emergency department (ED) with three days of sharp, substernal chest pain radiating down her left arm. She reportedly had a normal electrocardiogram (ECG) at an outside hospital on the first day of symptoms. The pain returned and was associated with one episode of vomiting the night prior to presenting to our ED. Initial ECG on arrival is shown.

Vitals: Tachycardic; afebrile; normotensive; no tachypnea or hypoxemia on room air

General: Mild distress, appears uncomfortable

Cardiovascular: Tachycardic to 100s, regular rhythm, no murmur, normal peripheral perfusion, no edema

Pulmonary: Lungs clear to auscultation, no respiratory distress

Neuro: Alert and oriented, neurologically intact

Complete blood count (CBC) and basic metabolic panel (BMP): unremarkable

Partial thromboplastin time (PTT) and international normalized ratio (INR): normal

Troponin: 42

Spontaneous coronary artery dissection (SCAD).

The patient underwent emergent coronary angiography demonstrating multivessel coronary dissection including a distal left anterior descending (LAD) hematoma with lumen compression as well as obtuse marginal (OM1) and posterior descending artery (PDA) lesions consistent with spontaneous coronary artery dissection (SCAD). She was admitted to the intensive care unit on a heparin drip, had decreasing troponin levels, and ultimately was discharged home on enalapril, metoprolol, aspirin, and clopidogrel.

SCAD is a rare but important diagnosis in the ED as it conveys serious morbidity and mortality risk. Patients present with chest pain, dyspnea, diaphoresis, and potentially signs or symptoms of heart failure from severe ischemia. Most patients are women under the age of 50, and many are pregnant, postpartum, or taking oral contraceptives. This may be mistaken for other diagnoses on presentation, such as ST-segment elevation myocardial infarction (STEMI) or takotsubo cardiomyopathy, which usually presents in post-menopausal patients, but SCAD differs in its typical patient population. Wall motion abnormalities on an echocardiogram are present, but there are not always signs of heart failure as in post-partum cardiomyopathy. Patients are often taken for urgent coronary angioplasty, though in cases with marked ischemia or hemodynamic instability, emergent coronary artery bypass graft (CABG) may be indicated. Recurrence is common; patients should be counseled on mitigating cardiovascular risk factors, particularly smoking and hypertension, and to be cautious with intense exertion and future pregnancies.

Sex, age, and postpartum status.

Take-Home Points

  • ECG typically shows ST elevation in the leads of the dissecting artery or arteries. Important risk factors include oral contraceptive use, being pregnant or postpartum, and fibromuscular dysplasia.
  • ED management includes aspirin, heparin, and immediate cardiology consultation, as a definitive diagnosis will be made in the cath lab.

  • Yip A, Saw J. Spontaneous coronary artery dissection-A review. Cardiovasc Diagn Ther. 2015 Feb;5(1):37-48. doi: 10.3978/j.issn.2223-3652.2015.01.08. PMID: 25774346; PMCID: PMC4329168.
  • Macaya F, Salinas P, Gonzalo N, Fernández-Ortiz A, Macaya C, Escaned J. Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management. Open Heart. 2018 Nov 5;5(2):e000884. doi: 10.1136/openhrt-2018-000884. PMID: 30487978; PMCID: PMC6241978.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

 

By |2021-10-26T20:58:04-07:00Nov 1, 2021|Cardiovascular, ECG, SAEM Clinical Images|
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Diagnosis on Sight: “I have a rapid heart rate”

A 31-year-old male presented to the emergency department with palpitations. The patient stated that he thinks his symptoms began “last night” and felt like he had “a rapid heart rate.” He said that prior to last night he felt fine. He did admit to drinking alcohol with his friends 2 nights prior. The patient estimated that he “must have drunk about 30 beers.” On review of systems, he reported feeling anxious. He denied illicit drug use, headache, chest pain, cough, shortness of breath, fevers, nausea, vomiting, abdominal pain, dysuria, or increased urinary frequency. He reported that he was unaware of any family history of early heart disease or sudden death. His initial EKG is shown below.

After consultation with cardiology, the decision was made to cardiovert the patient given the wide complex tachycardia.  After cardioversion, the resulting EKG is shown below:

On review of previous records, the patient had a recent ED visit 2 months ago with the EKG shown below:

What is the diagnosis?

Preexcited atrial fibrillation with underlying Wolf-Parkinson-White syndrome

Explanation:

Wolf-Parkinson-White (WPW) syndrome and the WPW pattern on EKG are rare disorders. Only 0.13 – 0.25% of the population have a WPW pattern on EKG [1,2]. However, only a small fraction of these people will develop WPW syndrome. WPW syndrome is defined as a symptomatic arrhythmia with a WPW pattern on EKG.

The patient’s initial EKG showed a wide complex tachycardia that was ultimately determined to be preexcited rapid atrial fibrillation. After cardioversion, the patient’s underlying baseline EKG tracing showed findings of Wolf-Parkinson-White with:

  • A shortened PR interval
  • Widened QRS complex
  • Delta wave: Slurred upstroke of the QRS complex

The most common arrhythmias associated with WPW syndrome are:

  • AV Reentrant Tachycardia (AVRT): Seen in over 90% of patients with WPW syndrome [3,4]
  • Atrial Fibrillation: 10-30% [5,6]
  • Atrial Flutter: Less than 5%

As in this case, AVRT (i.e. SVT) is often followed by atrial fibrillation in patients with WPW. Although the pathophysiology is unclear, up to 35% of instances of atrial fibrillation were preceded by AVRT [5,7,8].

Fortunately, fatal dysrhythmias such as ventricular fibrillation and ventricular tachycardia are very rare with WPW.

Case Conclusion:

Following cardioversion, the patient remained stable in sinus rhythm. After consultation with cardiology, the patient was discharged on Flecainide and Metoprolol and a referral for outpatient cardiology was placed for follow-up care. Soon after, the patient had an electrophysiology study that showed a left posterolateral accessory conduction pathway. He then underwent successful ablation of his orthodromic AVRT.

Want more visual stimulation? Check out the Diagnose on Sight archives!

 

References:

  1. Krahn AD, Manfreda J, Tate RB, et al. The natural history of electrocardiographic preexcitation in men. The Manitoba Follow-up Study. Ann Intern Med 1992; 116:456. PMID: 1739235
  2. Kobza R, Toggweiler S, Dillier R, et al. Prevalence of preexcitation in a young population of male Swiss conscripts. Pacing Clin Electrophysiol 2011; 34:949. PMID: 21453334
  3. Josephson ME. Preexcitation syndromes. In: Clinical Cardiac Electrophysiology, 4th, Lippincot Williams & Wilkins, Philadelphia 2008. p.339.
  4. Chugh A, Morady F. Atrioventricular reentry and variants. In: Cardiac electrophysiology from cell to bedside, 5th edition, Zipes DP, Jalife J (Eds), Saunders/Elsevier, Philadelphia 2009. p.605-614.
  5. Campbell RW, Smith RA, Gallagher JJ, et al. Atrial fibrillation in the preexcitation syndrome. Am J Cardiol 1977; 40:514. PMID: 910715
  6. Sharma AD, Klein GJ, Guiraudon GM, Milstein S. Atrial fibrillation in patients with Wolff-Parkinson-White syndrome: incidence after surgical ablation of the accessory pathway. Circulation 1985; 72:161. PMID: 4006127
  7. Sung RJ, Castellanos A, Mallon SM, et al. Mechanisms of spontaneous alternation between reciprocating tachycardia and atrial flutter-fibrillation in the Wolff-Parkinson-White syndrome. Circulation 1977; 56:409. PMID: 884796
  8. Fujimura O, Klein GJ, Yee R, Sharma AD. Mode of onset of atrial fibrillation in the Wolff-Parkinson-White syndrome: how important is the accessory pathway? J Am Coll Cardiol 1990; 15:1082. PMID: 2312962
By |2021-08-27T09:10:41-07:00Aug 25, 2021|Cardiovascular, Diagnose on Sight, ECG|
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SAEM Clinical Image Series: Another Heart Attack?

Another heart attack

[Figure 1: Click for larger view]

Chief Complaint: Chest pain

History of Present Illness: An 89-year-old female with a past medical history of coronary artery disease and with recent admission for myocardial infarction that was medically managed, presented with chest pain and shortness of breath. She reports worsening midsternal chest pain that occasionally radiates to her back and right arm since discharge.

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By |2019-07-28T21:30:40-07:00Jul 23, 2019|Cardiovascular, ECG, SAEM Clinical Images, Ultrasound|
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Ultrasound For The Win! – 57F with Chest Pain and Dyspnea #US4TW

Welcome to another ultrasound-based case, part of the “Ultrasound For The Win!” (#US4TW) Case Series. In this case series, we focus on a real clinical case where point-of-care ultrasound changed the management of a patient’s care or aided in the diagnosis. In this case, a 57-year-old woman presents with chest pain and dyspnea.

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By |2018-08-26T19:17:12-07:00Aug 27, 2018|Cardiovascular, ECG, Ultrasound, Ultrasound for the Win|
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Can’t Miss ECG Findings for the Emergency Medicine Provider

high-risk ECGSudden cardiac death accounts for almost 400,000 deaths per year in the United States, and EM providers must be adept at discerning subtle, high-risk ECG findings. With the advent of triage ECG protocols, one of the most common interruptions in the ED is a request to “sign off” on an ECG. We present a reference of some of the most important high-risk ECG findings, intended to help ED providers systematically screen patients in triage and the waiting room.
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By |2021-11-19T17:01:50-08:00Jul 11, 2018|ECG|
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QI Series: Pitfalls in Diagnosing Hyperkalemia

Clue copyA 55 year old male was brought to the Emergency Department (ED) by paramedics complaining of weakness and chest discomfort. His past medical history was notable for coronary artery disease with bypass grafting, diabetes mellitus, and end stage renal disease. He reported being non-compliant with his last 2 scheduled hemodialysis sessions. Paramedics noted pallor and recorded a blood pressure of 80/palpated and a heart rate of 44. Upon arrival to the ED, a 12 lead ECG was obtained.

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By |2016-11-11T19:17:44-08:00Dec 16, 2013|ECG, Endocrine-Metabolic|
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