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Abstract
Introduction: Coronary artery disease (CAD) is the leading cause of morbidity and mortality in the United States (reference). This disease most commonly manifests as chest pain; however, there is a broad range in the presentation of acute coronary syndrome, as some studies have suggested that more than 25% of all diagnosed myocardial infarctions have been clinically silent. Due to the lack of correlation between the seriousness of the disease and the intensity of symptoms, there are specific protocols that have been developed to help providers manage patients with acute chest pain appropriately. We present a patient with acute chest pain who became clinically asymptomatic after administration of morphine but was diagnosed with severe CAD requiring coronary artery bypass surgery. This case underscores the crucial role of evidence-based protocols in managing patients with acute chest pain, even after apparent clinical improvement.
Case Presentation: A 67-year-old lady with a known history of diabetes mellitus type 2, hypertension, and coronary artery disease status post percutaneous coronary intervention and two drug-eluting stents placed one year prior presented to the emergency department (ED) after she experienced substernal chest pain. The chest pain was rated 10/10 in intensity and pressure type, radiating to the left shoulder and back. The pain is aggravated by movement, partially relieved with sublingual nitroglycerin, and lasts approximately two hours. On admission, no abnormalities were noted on vitals and physical exam. Admission labs included a complete metabolic profile and blood count within normal limits. EKG revealed sinus rhythm with poor R wave progression. Additional workup included high sensitivity troponin elevated from 9 > 138 > 279 ng/L. She was diagnosed with acute coronary syndrome with non-ST elevation myocardial elevation with a TIMI and Heart score of 6 and 7 points, respectively. At the ED, she was administered morphine, and her symptoms completely abated. The patient was promptly started on goal-directed medical therapy with full- dose anticoagulation and antiplatelet therapy and was prepped for a left heart catheterization (LHC). At the LHC, a severe three-vessel coronary artery disease was diagnosed with 80% stent restenosis in the proximal left anterior descending artery, 70% stenosis of the mid left anterior descending artery, 90% stenosis of the ostial left circumflex, and an 80% stenosis of the proximal right circumflex artery. Based on these findings, the patient was transferred out from our facility to undergo a coronary artery bypass graft, and it was reported that she recovered well after the procedure.
Discussion: This case underscores the importance of adhering to established protocols and risk stratification in managing chest pain, even when the patient is clinically silent. A woman with a complex cardiac history presented with severe chest pain and was systematically evaluated, leading to a diagnosis of non-ST elevation myocardial infarction. Classified as high-risk using TIMI and Heart Score, urgent measures were taken. Coronary angiography revealed severe triple vessel disease, necessitating CABG despite symptom resolution. Adhering to current screening, testing, and treatment guidelines achieved favorable outcomes, emphasizing the necessity of comprehensive risk assessment and standardized care protocols for accurate diagnosis and management.
Presentation Type
Poster
Recommended Citation
Reckley, William; Olson, Kennedy; Kondapavuluru, Roy; Durazo, Yareli; Suarez, Andrez; and Balderas, Michael, "Silent Threat: Navigating the Complex Presentation of Severe Coronary Artery Disease Despite Symptom Relief" (2024). Research Colloquium. 85.
https://scholarworks.utrgv.edu/colloquium/2024/posters/85
Included in
Silent Threat: Navigating the Complex Presentation of Severe Coronary Artery Disease Despite Symptom Relief
Introduction: Coronary artery disease (CAD) is the leading cause of morbidity and mortality in the United States (reference). This disease most commonly manifests as chest pain; however, there is a broad range in the presentation of acute coronary syndrome, as some studies have suggested that more than 25% of all diagnosed myocardial infarctions have been clinically silent. Due to the lack of correlation between the seriousness of the disease and the intensity of symptoms, there are specific protocols that have been developed to help providers manage patients with acute chest pain appropriately. We present a patient with acute chest pain who became clinically asymptomatic after administration of morphine but was diagnosed with severe CAD requiring coronary artery bypass surgery. This case underscores the crucial role of evidence-based protocols in managing patients with acute chest pain, even after apparent clinical improvement.
Case Presentation: A 67-year-old lady with a known history of diabetes mellitus type 2, hypertension, and coronary artery disease status post percutaneous coronary intervention and two drug-eluting stents placed one year prior presented to the emergency department (ED) after she experienced substernal chest pain. The chest pain was rated 10/10 in intensity and pressure type, radiating to the left shoulder and back. The pain is aggravated by movement, partially relieved with sublingual nitroglycerin, and lasts approximately two hours. On admission, no abnormalities were noted on vitals and physical exam. Admission labs included a complete metabolic profile and blood count within normal limits. EKG revealed sinus rhythm with poor R wave progression. Additional workup included high sensitivity troponin elevated from 9 > 138 > 279 ng/L. She was diagnosed with acute coronary syndrome with non-ST elevation myocardial elevation with a TIMI and Heart score of 6 and 7 points, respectively. At the ED, she was administered morphine, and her symptoms completely abated. The patient was promptly started on goal-directed medical therapy with full- dose anticoagulation and antiplatelet therapy and was prepped for a left heart catheterization (LHC). At the LHC, a severe three-vessel coronary artery disease was diagnosed with 80% stent restenosis in the proximal left anterior descending artery, 70% stenosis of the mid left anterior descending artery, 90% stenosis of the ostial left circumflex, and an 80% stenosis of the proximal right circumflex artery. Based on these findings, the patient was transferred out from our facility to undergo a coronary artery bypass graft, and it was reported that she recovered well after the procedure.
Discussion: This case underscores the importance of adhering to established protocols and risk stratification in managing chest pain, even when the patient is clinically silent. A woman with a complex cardiac history presented with severe chest pain and was systematically evaluated, leading to a diagnosis of non-ST elevation myocardial infarction. Classified as high-risk using TIMI and Heart Score, urgent measures were taken. Coronary angiography revealed severe triple vessel disease, necessitating CABG despite symptom resolution. Adhering to current screening, testing, and treatment guidelines achieved favorable outcomes, emphasizing the necessity of comprehensive risk assessment and standardized care protocols for accurate diagnosis and management.