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JAMA Clinical Challenge
December 18, 2018

A Young Woman With Chest Pain

Author Affiliations
  • 1Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 2McGaw Medical Center of Northwestern University, Chicago, Illinois
  • 3Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
JAMA. 2018;320(23):2476-2477. doi:10.1001/jama.2018.17045

A 36-year-old healthy gravida 3, para 3 woman with a history of asthma and elective cesarean delivery 11 days prior presented to the emergency department with 3 days of exertional chest pain. The pain was described as crushing and substernal, but she denied radiation or associated dyspnea, nausea, vomiting, or diaphoresis. On physical examination, her blood pressure was 167/105 mm Hg bilaterally, heart rate was 71/min, respiratory rate 18/min, and oxygen saturation 98% on room air. Initial laboratory evaluation revealed a troponin I level of 0.12 ng/mL (reference range, 0.00-0.04 ng/mL). An electrocardiogram showed normal sinus rhythm with diffuse ST-segment depressions but without q waves or ST-segment elevation (Figure, left). Computed tomography angiography did not show pulmonary embolism or aortic dissection. Echocardiography demonstrated a left ventricular ejection fraction of 53%, with apical akinesis and no valvular disease.