Chest Pain and Troponin Leak in a Healthy 38-year-old Female

Abstract

A 38-year-old female with a medical history significant only for a cholecystectomy for cholelithiasis presented to an outside hospital with a one day history of sharp, non-radiating midsternal chest pain that began when she bent over to pick something up. She has associated light-headedness and dizziness when she stood up, as well as palpitations, diaphoresis, and a sense of throbbing in her left arm. The symptoms persisted at rest for one hour before the patient arrived at the outside hospital. She was found to be in new-onset atrial fibrillation with a rapid ventricular rate up to 160 beats per minute. A diltiazem infusion was started which resulted in a decrease of the heart rate to 100 beats per minute. Her first troponin was <0.05 ng/ mL, but a subsequent troponin was 0.59 ng/mL, prompting the initiation of a heparin infusion for acute coronary syndrome. At this point, she was transferred to Thomas Jefferson University Hospital for further management. Her chest pain had resolved without any other medication, and she remained chest pain free through the rest of her hospital course. Of note, she admitted to using alcohol, tobacco, and cocaine two days prior to admission. Her only medication is a daily oral contraceptive pill.Her initial vital signs on transfer were a temperature of 97.9 degrees Fahrenheit, blood pressure of 97/63 mm Hg, heart rate on 112 beats per min, which was irregularly irregular, and respiratory rate of 20 breaths per minute with an oxygen saturation of 98% on room air. Her physical exam was significant for an enlarged left palatine tonsil, irregular heart rate, and ecchymosis on her neck.Initial laboratory studies included a white blood cell count of 12,000 /L, hemoglobin of 14.1 g/dL, platelet count of 269,000 /L, creatinine of 1.1 mg/dL, AST 48 IU/L, and ALT 41 IU/L. Her maximum troponin was 0.59 ng/mL. Subsequently, her rhythm converted to sinus rhythm. Her EKG showed sinus tachycardia, but no ST-T changes concerning for myocardial ischemia or infarction.A cardiac catheterization was done with images as shown below.Questions: Select the one lettered answer that is BEST in each question.