Recurrent Chest Pain with ST-Segment Elevation

Mar 08, 2021   |  Mohamed M Gad, MD; Beni Verma, MD; Hassan Mehmood Lak, MD; Vardhmaan Jain, MD; Agam Bansal, MD; Allan L. Klein, MD, CM, FACC
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A 79-year-old female with past medical history significant for post-polio syndrome complicated by diaphragmatic weakness, restrictive lung disease, recurrent pneumonia complicated by respiratory failure, chronic mycobacterial pulmonary abscesses, bronchiectasis, moderate pulmonary hypertension, and obstructive sleep apnea presented to the emergency room (ER) with sudden onset chest pain that woke her up from sleep. She describes the pain as spreading from shoulder to shoulder and creeping up her jaw. It was dull, 6/10 in severity, and was not worse with breathing nor associated with diaphoresis. She described epigastric pressure, palpitations and shortness of breath (SOB) with eating that would last a few hours after eating. As the pain woke her up from sleep and was new for her, she called Emergency Medical Services (EMS) and was transported to the ER. She received aspirin and nitroglycerin by EMS, with no relief of symptoms.

In the ER, she was afebrile and hemodynamically stable. Her initial electrocardiogram (ECG) showed ST-segment elevation in leads II, III, aVF, V3-V6, and T-wave inversions in aVR and V1 (Figure 1). Her labs showed a high-sensitivity troponin of 29 ng/L (reference range <12 ng/L). Contrast-enhanced CT chest, pulmonary embolism protocol, was negative for pulmonary embolism, aortic dissection, and pericardial effusion.

Figure 1

Figure 1

While in the ER, the patient had another episode of chest pain that was associated with ST-segment elevation in leads II, III, aVF, V4-V6 and T-wave inversions in V1-V3 (Figure 2).

Figure 2

Figure 2

The pain resolved with the use of sublingual nitroglycerin. Repeat high-sensitivity troponin came back as 23 ng/L, ESR was 28 mm/hr (reference range 0-20 mm/hr), and CRP was 6.8 mg/dL (reference range < 0.9 mg/dL). Bedside echocardiography showed a hyperdynamic systolic function with an ejection fraction (EF) of 75%, upper septal left ventricular hypertrophy, Grade I left ventricular diastolic dysfunction, RVSP of 59 mmHg, and a small pericardial effusion measuring 0.4 cm (Figure 3). The patient was started on aspirin 650 mg 3 times a day, and colchicine 0.6 mg daily for management of acute pericarditis. The patient was discharged with an aspirin taper over 2 months and colchicine 0.6 mg daily.

Figure 3

Figure 3

Three weeks later, the patient had recurrence of her chest pain associated with SOB. Her exam was mostly unchanged with cardiac exam showing normal S1 and S2, no murmurs, no pericardial rub or knock, no jugular venous distention, no Kussmaul's sign, and no peripheral edema. Her inflammatory markers were elevated compared to time of diagnosis; ESR was 56 mm/hr, and CRP was 8.3 mg/dL. Echocardiography was performed and showed EF of 71% with a significant interval increase in the size of the pericardial effusion now measuring 1.9 cm with some organization and a brief right atrial inversion. No significant mitral respiratory variation or definite tamponade physiology were noted (Figure 4).

Figure 4

Figure 4

Which one of the following statements is true in this case?

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