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JAMA Cardiology Clinical Challenge
April 4, 2018

Acute Coronary Syndrome in a 44-Year-Old Woman

Author Affiliations
  • 1Internal Medicine, Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania
  • 2Interventional Cardiology, Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania
JAMA Cardiol. Published online April 4, 2018. doi:10.1001/jamacardio.2018.0516

A 44-year-old African American woman without traditional atherosclerotic risk factors or known coronary artery disease (CAD) presented to the emergency department with chest pain. She had 3 previous pregnancies (2 live births and 1 spontaneous abortion); her last child was born more than 5 years ago. Her chest pain began spontaneously 1 hour prior to presentation and was described as retrosternal with radiation to her upper and middle back.

On physical examination, her blood pressure was 128/88 mm Hg, her pulse was regular at 96 beats per minute, her respiratory rate was 16 breaths per minute, and her temperature was 36.9° C. Pulse oximetry was 100% in room air. The chest was nontender. Pertinent physical findings included normal central venous pressures, clear lung fields, normal first and second heart sounds, an audible fourth heart sound, and no murmurs. The electrocardiogram (Figure 1A) demonstrated anterior ST-segment elevations consistent with an anterior acute current of injury. Results from the chest radiography were normal. Initial troponin I concentration was 0.02 ng/mL but rose to 177.76 ng/mL over the ensuing 4 hours (the patient’s chest pain had resolved by this time). Urgent coronary angiography was performed (Figure 1B). Thrombolysis in myocardial infarction flow grade 2 was observed in the left anterior descending artery and second diagonal branch.

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