AHRQ WebM&M: Morbidity and Mortality Rounds on the Web
A Real Heartache
Commentary by Steven K. Polevoi, MDThe Case | |
A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The pain began at rest, and it radiated to his back and left axilla. He had no other complaints and reported being in good health otherwise. His past medical history was notable for a history of depression, a 40-pack/year history of cigarette smoking, and a father who had a heart attack at age 49. On physical examination, his initial blood pressure was elevated at 192/100 mm Hg, but his heart rate and the rest of his cardiopulmonary examination were normal. Bilateral upper-extremity blood pressures were equal. An electrocardiogram (ECG) was obtained (Figure 1) and interpreted as unremarkable. A chest radiograph and routine blood work, including a troponin assay, were also normal. The patient received aspirin and sublingual nitroglycerin without symptom improvement. Subsequently, a "GI cocktail" (an oral antacid/anesthetic combination) was given, and the patient reported symptom relief; his blood pressure also normalized. Convinced that a cardiac etiology had been ruled out because of the atypical pain, the unremarkable ECG, the normal troponin, and the response to the GI cocktail, the ED physician discharged the patient to home with a presumptive diagnosis of gastroesophageal reflux disease (GERD). The patient was advised to follow up with his primary care physician.
Two days later, the patient made an unscheduled return visit to the ED, now in severe distress. He complained of abdominal pain and was dyspneic, hypotensive, and with mottled skin. Fluid and pressor support was initiated, and the patient was intubated. ED physicians obtained an ECG (Figure 2), which showed ST-segment elevation, prompting urgent cardiology consultation with concern for an acute myocardial infarction and/or aortic dissection. A bedside echocardiogram revealed a large pericardial effusion, and the patient was taken urgently to the cardiac catheterization lab. Cardiac catheterization showed branch occlusion of the left circumflex coronary artery. The patient stabilized and further evaluation did not reveal a myocardial rupture. Two days later, the patient had a cardiac arrest and could not be resuscitated. An autopsy revealed 3-vessel atherosclerotic coronary artery disease and a 4-day-old transmural myocardial infarct with extension and associated rupture of the left ventricular free wall. The consensus of the ED quality committee's case review was that the patient had a diagnosis of myocardial infarction, which was missed at his initial presentation.
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