13. Case of the month: chest pain

Case and images James Dent

A 44F presents with chest pain for 20 mins, central chest reflux/burning sensation. Onset on leaning forward to open drawer. Now just in left shoulder. Then tingling to bilateral hands, feet and generalised and spasming of hands.  Recently well

OE: eyes closed, SaO2 100%  on room air, HR 82, BP 135/90, RR 18, 36.9

Nil PMH, nil regular meds, NKDA, non-smoker

This is her chest Xray

What are your thoughts?

Her initial treatment

  • Analgesia (paracetamol)
  • Pink lady
  • PPI

This was her ECG

Her biochemistry and haemtology came back. Of note:

  • Troponin 19
  • WCC 10.2

On the strength of the troponin, a second ECG was performed

An ECHO was performed. This is the PSAX view

What is the abnormality that you can see? What areas of the myocardium are supplied by the LAD, the LCx and the RCA?

There is a regional wall abnormality affecting the septal/anterior wall of the LV. Look for the hinge points . The hinge point is the point at which the myocardium does not contract as well . The area which is poorly contracting is supplied by the LAD.

This is the 4CV. What can you see?

Again here we can see a regional wall abnormality involving the distal 1/3 of the IVS, and the apex. Watch for the change in movement between the normal contracting myocardium and the abnormaly contracting myocardium.

These are the hinge points

Repeat troponins were performed .

  • day 1 19.02 : 19ng/l
  • day 1 21.05 : 810 ng/l
  • day 2 05.15 : 2,249 ng/l

She was admitted for an angiogram and a heparin infusion was commenced
The angiogram showed : LAD distal third 95% stenosis, LAD lesion has a tubular shape, consistent with SCAD
A relook angiogram a few days later showed :  mid LAD 99% lesion, grade 3 dissection
She was discharged 10/7 from presentation on oral aspirin, clopidogrel and bisoprolol

She was followed up at the SCAD clinic follow up

The impact of the  point of care echo on this patient were:

  • The echo showed regional wall motion abnormality in LAD region before the troponin  rose to 800+
  • Increased index of suspicion and interest from cardiology (prior to 2nd trop)

Take home point:
A bedside echo can be helpful to visualise regional wall motion abnormalities in patients with ECG changes/ elevated troponin. Look for subtle changes in wall motion. Look for hinge points.







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