Clinical Scenario: Unraveling the Mystery of Chest Pain
Patient Information: Mr. James Anderson, a 58-year-old male, presents to the emergency department with severe chest pain and shortness of breath.
He has a past medical history of hypertension, for which he takes medication irregularly.
His family reports that he has been under intense psychological stress due to work-related issues for the past week.
In addition, he has had a fever of 101°F (38.3°C) for the last two days and has been taking over-the-counter antipyretics.
Mr. Anderson complains of sudden-onset, severe, crushing chest pain that radiates to his left arm.
He rates the pain as 9/10 in intensity and describes it as a tight, squeezing sensation.
He feels clammy and nauseated. The pain started approximately 45 minutes ago while he was at home.
Clinical Assessment: On examination, Mr. Anderson appears diaphoretic and in distress. His vital signs are as follows:
- Blood pressure: 170/100 mm Hg
- Heart rate: 110 bpm
- Respiratory rate: 22 breaths/min
- Oxygen saturation: 96% on room air
A 12-lead electrocardiogram (ECG) is obtained, showing ST-segment elevation in leads II, III, and aVF. Cardiac enzymes are ordered for serial measurement.
- ECG findings suggestive of ST-segment elevation myocardial infarction (STEMI).
- Elevated cardiac troponin levels on initial blood work.
Clinical Impression: Mr. Anderson presents with chest pain, ECG changes consistent with STEMI, and elevated cardiac troponin levels.
This clinical picture is indicative of acute coronary atherothrombosis (Type 1 MI) precipitated by acute coronary thrombosis.
- Immediate activation of the catheterization lab for primary percutaneous coronary intervention (PCI).
- Administration of aspirin, clopidogrel, and heparin to prevent further thrombosis.
- Nitroglycerin for chest pain relief.
- Intravenous fluids and oxygen supplementation.
- Continuous cardiac monitoring.
While Mr. Anderson’s presentation initially raised concerns about the role of psychological stress and fever in precipitating unstable ischemic symptoms, the clinical assessment, ECG findings, and cardiac enzyme elevation pointed towards acute coronary thrombosis as the primary cause.
This case highlights the importance of distinguishing between different types of myocardial infarction to guide appropriate therapeutic strategies and emphasizes that even in the presence of potential precipitating factors like stress and fever, acute coronary syndrome must be considered and managed promptly.
- “Harrison’s Cardiovascular Medicine” – Page 376 📖
- “Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine” – Page 543 📖
- “Cardiology Secrets” – Page 210 📖
- “The ESC Textbook of Cardiovascular Medicine” – Page 678 📖
- “Cardiovascular Physiology Concepts” – Page 132 📖
- “Cardiac Catheterization Handbook” – Page 89 📖
- “Pathophysiology of Heart Disease” – Page 301 📖
- “Cardiovascular Hemodynamics for the Clinician” – Page 174 📖