A Woman With Chest Pain, Syncope, and Transaminitis

Abstract

The patient is a 49 year-old female with past medical history of anxiety and hyperlipidemia who presented to an outside hospital with complaints of five hours of substernal chest pain followed by three episodes of syncope witnessed by her son. At presentation in the emergency department the patient denied any current chest pain or shortness of breath. She received 325 mg of aspirin en route to the hospital by EMS. Her vital signs were temperature 100° Fahrenheit, heart rate 60 beats/minute, blood pressure 101/50 mm Hg, respiratory rate 20 breaths/minute, and a pulse oxygenation of 98% on room air. The patient's EKG showed ST elevations in the inferior leads. The patient's laboratory studies were: white blood cell (wbc) count 14 B/L, hemoglobin 13.2 g/ dL, platelets 153 B/L, CKMB 32 U/L, troponin 8.27 ug/L, and CK 24.5 U/L. The patient was started on intravenous heparin and integrillin drips and transferred to Jefferson for emergent cardiac catheterization.The patient had left and right coronary angiography which showed no evidence of occlusive coronary disease. Left heart catheterization demonstrated moderate to severe inferoapical hypokinesis and a mildly depressed left ventricular ejection fraction (40%). During the procedure, the patient was noted to have 2:1 AV heart block with intraventricular conduction delay, and a temporary transvenous pacemaker was placed. The patient was then transferred to the cardiac care unit.In the cardiac care unit, the patient reported that she had no known drug allergies. Her only outpatient medication was a statin that was started six weeks ago. The patient denied any past surgical history. The patient consumed alcohol socially, had a 15 pack year history of smoking, and no history of illicit drug use. The patient's father died of a myocardial infarction at age 62, and the patient's mother was alive with a history of diabetes mellitus and arrhthymia. The patient noted that she had some nasal congestion for two days prior to the chest pain and syncope. The patient also reported working in her garden with rose bushes and was certain that she had a neck rash due to poison oak. Lastly, the patient reported decreased oral intake for the past two days due to "flu-like" disease.Overnight, the patient had multiple episodes of bradycardia that warranted venous pacing on telemetry. Significant laboratory studies were: wbc 4.3 B/L, AST 539 U/L, ALT 313 U/L, and troponin 14.7 ug/L. The patient underwent successful implantation of a dual chamber VDD pacemaker. A transthoracic echocardiogram demonstrated an ejection fraction of 60%, mild to moderate mitral regurgitation, and an inferior vena cava normal in size without inspiratory collapse. The patient was transferred to the telemetry floor service.On the third hospital day, the patient had no overnight complaints and wanted to be discharged home. Significant laboratory studies were a troponin of 16.5 and AST 299 U/L, and ALT 250 U/L. The patient had a CT of her head which showed no fracture or bleed. A CT of her chest demonstrated multifoca...