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JAMA Cardiology Clinical Challenge
March 2017

A Woman in Emotional Distress With Chest Pain

Author Affiliations
  • 1Division of Internal Medicine, Mayo Clinic, Rochester, Minnesota
  • 2Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
JAMA Cardiol. 2017;2(3):337-338. doi:10.1001/jamacardio.2016.4230

A woman in her late 50s with a history of multiple sclerosis, without traditional atherosclerosis risk factors and not taking medications, presented to the emergency department after having 30 minutes of pain in her left shoulder and vague chest pressure that had already resolved. There were no associated symptoms. Her daughter had died unexpectedly a few days before presentation, and the burial service was scheduled for that day. Except for the patient appearing struck with severe grief, the results of an initial physical examination, electrocardiography (ECG), and radiography of the chest and her initial laboratory results were all unremarkable. Her serial troponin T levels were less than 0.01, 0.04, and 0.1 ng/mL (normal range, <0.01 ng/mL [to convert to micrograms per liter, multiply by 1.0]). An emergency transthoracic echocardiographic biplane volumetric assessment of left ventricular (LV) function is shown in Figure 1 (Video 1 and Video 2). She received aspirin, high-intensity statin, and low-dose β-blocker and was given a therapeutic dose of low-molecular-weight heparin subcutaneously. Serial ECGs were unchanged, and the patient was completely asymptomatic; thus, she was permitted to briefly attend her daughter’s burial service as long as she returned immediately for direct hospital admission. Twelve hours after readmission, she was asymptomatic, her troponin level had increased to 2.0 ng/mL, and she again underwent ECG (Figure 1).