A 32-year-old male smoker presented to his local emergency department (ED) after two days of chest pain radiating to both arms. The pain, which had last occurred one hour prior to presentation, occurred at rest and was associated with shortness of breath and palpitations. The patient denied any drug use. He told the triage nurse his father had suffered an MI at age 35.
In the ED, the patient, who also presented with a hard cough, was found to be tender over the anterior part of his chest wall; his EKG and chest X-ray were read as normal (no enzymes test done). The patient was diagnosed with costochondritis and sent home with anti-inflammatory medications, narcotic pain medications, antibiotics, and instructions on chest pain. The patient’s vital signs at discharge were not recorded; he was noted to be pain-free.
Eight hours later, the patient returned to the ED complaining of crushing chest pain, shortness of breath, dizziness, and radiation of his pain to his left arm. He told the triage nurse, “I was just discharged, but I’m still having chest pain.” He was seen by a different physician and he now reported cocaine use a week prior. This attending interpreted a repeat EKG as showing elevations of the patient’s ST segments in the inferior leads consistent with an acute inferior myocardial infarction. He was given aspirin and morphine, and was placed on heparin and nitroglycerin. His cardiac enzymes were negative. He was immediately transferred to a tertiary teaching hospital for emergent cardiac catheterization.
During this history taking at the receiving hospital, the patient explained that his father had had his first MI at age 20, and died of an MI at age 37. The cardiology service took the patient to the catheterization lab. Almost 12 hours after his initial visit to the community hospital, the patient’s repeat cardiac enzymes were positive for a myocardial infarction. Catheterization revealed 95 percent left circumflex stenosis. A stent was placed and medications were started. Two days later, an echocardiogram performed prior to discharge revealed a significantly reduced ejection fraction of 35 percent. At discharge, the patient was pain free.
Six days later, the patient was readmitted to the cardiology service with a recurrence of his chest pain. His diagnostic work up, including a repeat catheterization, did not reveal significant disease. His medical treatment was optimized and he was discharged home.