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JAMA Cardiology Clinical Challenge
June 12, 2019

A Woman With Multiparity Experiencing Chest Pain in Her Early 60s

Author Affiliations
  • 1Department of Internal Medicine, Columbia University Medical Center, New York, New York
  • 2Department of Cardiovascular Diseases, Columbia University Medical Center, New York, New York
JAMA Cardiol. 2019;4(7):710-711. doi:10.1001/jamacardio.2018.4511

A woman in her early 60s with a medical history of chest pain requiring a coronary angiogram (which demonstrated only mild luminal irregularities) approximately 1 year prior to presentation, hypertension, long-standing dyslipidemia, and multiparity presented to the emergency department with a sudden onset of dull, pressurelike chest pain radiating to the left arm. The pain started at rest, was 10 of 10 in severity, and was not alleviated by changing position. She also experienced concomitant nausea and diaphoresis. Her family history was notable for hypertension, and no other systemic diseases were reported. On physical examination, her blood pressure was 115/76 mm Hg, heart rate was regular at 72 beats per minute, respiratory rate was 20 breaths per minute, and oxygen saturation level was 98% on room air. The patient was afebrile. Physical examination also revealed mild bibasilar crackles and jugular venous distention, and no murmurs or lower extremity edema. Laboratory test results demonstrated an elevated troponin, and the 12-lead electrocardiogram showed marked ST-segment elevations in leads V2 to V5 (Figure, A). The ST-segment elevation myocardial infarction (STEMI) pager was activated, and the patient was transferred urgently to the catheterization laboratory. Coronary angiography of the patient’s left anterior descending coronary artery was performed, and the findings are depicted in the Figure, B.