A 50-Year-Old Female Presenting With Chest Pain in the Emergency Department

A 50-year-old African-American female presents to the emergency department with a 6-hour history of worsening left-sided chest and back pain. Chest pain is described as a moderate intensity, constant, sharp pain which is present at rest and is not worsened by activity. She has a 20 pack/year smoking history. Her mother was diagnosed with coronary artery disease at age 50. Her blood pressure is 130/70 Electrocardiogram shows sinus rhythm with no evidence of ST or T wave abnormalities. Serial troponins are negative. Hemoglobin A1c is 6. Total cholesterol 180, HDL 30, LDL 140. Chest X-ray is normal with no evidence of mediastinal widening, no lung infiltrates and no evidence of pulmonary vascular congestion. Her chest pain does not improve with sublingual nitroglycerin, but resolves with gastrointestinal cocktail.

A coronary CT angiogram is ordered which showed a left dominant system and evidence of non-obstructive plaque (figures I-III). Coronary calcium score is 189, which is > 95th percentile for age/gender/race (see table 1). Her Segment Involvement Score (SIS) is 3, Segment Stenosis Score (SSS) is 0 and CT-Leaman Score (CT-LeSc) is 9 Smoking cessation is recommended.

She requests your recommendations about her long-term risk for cardiac death and non-fatal acute coronary syndrome compared to a person with no coronary plaque:

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