Shot through the heart. Wards 101 1.18.2019

At wards 101 we talked about a 50 year old female with scleroderma, pulmonary HTN, OSA and T2DM who presented to the ED with progressive SOB and new onset chest pain. She described the pain as substernal, squeezing/pressure and unrelieved with rest. EKG showed sinus tachycardia and her bedside ECHO was without gross abnormalities. Troponin however was elevated at 2.5. An extensive work up was done and negative and her chest pain subsided on it’s own. Troponin peaked at 3 and then returned to normal over her hospitalization. She did have a history of Raynaud’s and Rheum was eventually consulted. She was started on nifedipine and her chest pain was thought to be secondary to vasospasm from her scleroderma. Her SOB thought to be worsening pulmonary HTN.

Remember, chest pain can be caused by many things and your questioning needs to be directed at figuring out which underlying pathology is there: ACS, PE, aortic dissection are what will kill patients quickly and need to be extensively asked about. Anemia, CHF can cause chest pain along with SOB and should be asked about as well.

Patients with scleroderma are at risk for ACS (they have higher likelihood of developing atherosclerotic disease) as well as myocarditis and they also have microvascular changes present before overt disease. Once they have cardiac involvement their prognosis is poor.

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