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JAMA Cardiology Clinical Challenge
May 12, 2021

A Middle-aged Man With Sharp Chest Pain

Author Affiliations
  • 1Division of Cardiovascular Medicine and Cardiothoracic Surgery, Catholic Health Initiatives Franciscan, Tacoma, Washington
  • 2Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Cardiol. Published online May 12, 2021. doi:10.1001/jamacardio.2021.0954

A man in his mid-50s with a medical history significant for pulmonary embolism 10 years prior (previously receiving anticoagulation therapy) presented to the emergency department with 10 days of progressively worsening, sharp, nonradiating chest pain. The pain was present at rest, 7 of 10 in severity, and worse with inspiration. He experienced concomitant exertional shortness of breath, dry cough, and lightheadedness. His cardiac history was otherwise unremarkable. Family history was notable for breast cancer in his mother and his sister, but no known inherited hypercoagulable disorders. In the emergency department, his vital signs were as follows: temperature 37.0 °C, blood pressure 130/76 mm Hg, heart rate 97/min, respiratory rate 16/min, and oxygen saturation of 95% on room air. Physical examination results were unremarkable, with no cardiac murmurs, rubs, pulmonary crackles, jugular venous distention, or lower extremity edema. Laboratory test results were remarkable for an elevated D-dimer level, an elevated C-reactive protein level and erythrocyte sedimentation rate, and a mildly elevated pro-BNP level, but normal levels of troponin and procalcitonin. An electrocardiogram showed normal sinus rhythm with evidence of right heart strain, and a computed tomography angiogram of the chest demonstrated an occlusive pulmonary embolism of the left main pulmonary artery and several peripheral consolidations in the left lower lung field consistent with infarction. The patient started anticoagulation therapy with intravenous heparin. A subsequent echocardiogram revealed bowing of the interventricular septum into the left ventricle and a very large (6.6 × 4.1-cm), mobile, nonhomogeneous, pedunculated mass straddling the tricuspid valve and moving between the right atrium and right ventricle (Figure 1 and Video).

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