21 yo ACS: is it ACS or did we miss something?

[OVeractiveBrain]

Pt is a 21 yo african american female who was out at a company party at a sports center (an oversized gym) playing indoor soccer with coworkers. While playing, for about 15 minutes, she felt faint, developed chest pain (described as sharp stabbing pain in the center of her chest, radiating to the back), heart rate remained tachycardiac at 120 and regular, per the trainer, and EMS was called. When we arrived she was resting comfortably in a chair, without CP, without SOB, without N/V without dizziness. Her heart rate was in the 120s, sinus tach on the monitor, BP 130/80, PEARL, lung sounds clear though she had a non-productive cough that started since the event, 12-lead non-diagnostic with a notched p-wave in V1 indicative or right sided atrial enlargement, PMS x4, GCS: 15, CAOx4, without JVD without tracheal deviation and without any signs or event of trauma, sp02 100% on room air, blood sugar: 110. She was a fit looking young woman, though she did report that she does not exercise often, despite her fit appearance. She has no history, no allergies, and takes birth control, had her last period 2 weeks ago, sees her doctor regularly, and works for a local area hospital as a registration assistant.

We treated her as though she were an ACS patient, establishing an IV, keeping her on the monitor, 12-leads, 02, and ASA. Other medications were withheld due to the absence of pain, ST-segment changes, or Q waves.

there are a number of potential differentials here. (1)She possibly had an Acute Coronary Event. (2)She has had some sort of AAA or aortic dissection (pain radiating from chest to back, higher risk from HTN and african-american) though she was nonorthostatic and did not have pulses paradoxsis. (3) Athletic Asthma induced respiratory acidosis which the heart responded by increasing flow to accommodate (the cough).

I know that ACS can present in a variety of ways. This seems to be a case of a 21 year old exertional angina without any family or social history that would predispose her to the condition (no family history of PVD, cardiomyopathies or vascular events; no history of her own at all, though she has regular doctors visits). I was worried about a potential embolus from her birth control, though no st-segment changes were noted and she was pain free upon resting. I did not get a chance to follow up with this patient, as the hospital we went to was over an hour away from my house (another medic internship call).

This sounds an oftly alot like an exertional angina, despite the lack of any predisposing factors. At the very end of the all she said that she felt a throat pain before, upon exertion. this time she felt both the throat and the chest pain. This leads me to believe the event was coronary even more (repeated exertional angina).

I post this only because this is a young woman who should definitely NOT be having a coronary event, though seems to be. Did we miss something in our assessment? Have i not thought of a potential differential diagnosis that adequately addresses all our findings? Treating her as an ACS patient I feel is absolutely the right thing to do, given our findings, but is there a piece of information we missed or some disease process we did not think about?

[medic001918]

It's possible that she pulled muscle or had some other physical ailment from the fact that she was engaged in a physical activity that she is not used to participating in. Ever talk to someone who has just started an excercise program and hit the gym (or other activity) to hard? These people will often complain of chest pain, shortness of breath and other aches and pains. I know when I used to run and I had just started, I'd have pain in the middle of my chest that was sharp and stabbing that had nothing to do with my heart.

It is the time of year for people to be getting sick. The additional physical exertion can bring on many manifestations of the common coughs and colds that we generally wouldn't see on a day to day basis.

My guess is that this patient was not having a cardiac event occuring, but some other physical condition. While it's not wrong to treat this patient for ACS, I'm thinking from what you've posted that I would have gone the routine ALS route at best. It's always advisable to go on the side of caution, but at the same time you don't always have to find a major cause of an event. Sometimes it's smaller things that look something major.

Good luck,

Shane

NREMT-P

[MrSpykes]

I agree with Shane. This was probably not anything significant but still better safe than sorry. Some other problems that could manifest with these symptoms that i thought of while reading this was a pulmonary embolus or a sickle cell crisis. Although someone 21yo would probably know if they had sickle cell anemia at this stage in her life. Another thought is just maybe some plain old pleuritic chest pain. What did her lungs sound like. A lot of times you can hear some junk or crackle like noise right over where the pain is/was if it is pleuritic chest pain. Routine ALS is the route I would have went too. Its too difficult to rule out anything cardiac with this patient.

[AZCEP]

It sounds like you did the right thing by not letting age and appearance to cloud your judgement.

The fact she is relatively young tends to put providers off their guard for ACS, but it can still happen. Is it common in the young and healthy? No, but if they have a cardiovascular system, it can still occur.

Were there any other leads on the 12 lead that showed notched P-waves? Typically, the right atrial enlargement will have an abnormally tall P-wave without a notch, while the left atrial enlargement will produce a wider than normal, notched P-wave. If there are other signs of a cardiac event, perhaps there is something in the history that was overlooked. You might not have had the chance to go deep enough to find it, and it might not be there anyway.

I do agree with Shane that the presentation could very well be a response to a seasonal infection. It would be good to follow up on this one, just to find out what actually happened.

[tniuqs]

Well from your detailed summary looks like you were very diligent to be sure.

I would add that besides the differencial diagnosis that have been provided, perhaps you should include Costalchondritis as this is quite a favorite complaint with my current "wards" with a "seasonal virus" cough leading too......when you hear the "sound hoof beats" think horses not zebras.....

cheers

[ERDoc]

In a young person with exertional chest pain and presyncope I would be concerned about IHSS. Here are a couple of articles that might be of interest:

http://www.emedicine.com/med/topic290.htm

http://www.umm.edu/ency/article/000192.htm

http://www.nlm.nih.gov/medlineplus/ency/article/000192.htm

No more physical exertion until you see the cardiologist.

[tniuqs]

In a young person with exertional chest pain and presyncope I would be concerned about IHSS. Here ar

No more physical exertion until you see the cardiologist.

Question pops into my head, would there be any widening of the QRS complex to give us a hint of IHSS?

[vs-eh?]

As with all things based on clinical assessment, you have to weigh certain things...

All things being equal, and based on the assessment as you described, I would not have treated this patient as ACS, and this easily could have been a BLS (PCP) transport here...And we have less assessment tools (i.e. no 12 lead) where I work.

It falls back into the question (perhaps more so prehospital) that, "Do you treat all chest pain as ischemic?" After all, it could be atypical/unusual presentation. You have to play it safe... In my opinion, you can't simply follow that mantra, and you have to weigh things (as long as you can justify it).

Is the hospital going to treat it as ACS if she walked in off the street? Given her signs and symptoms now? I would wager no.

Do you treat every drunk (regular or otherwise) experiencing chest pain (could be "normal" or not) as ischemic? Every 30 year old "panic attack" chest pain with a history of anxiety that feels the slightest of difference as ischemic CP?

As you gave in your differentials, it could also (perhaps an argument could be made, potentially more so) be a AAA or thoracic aneurysm. You obviously weighed it as more to the ACS side. However your treatment obviously would vary....in that the ASA you gave could now be potentially detrimental...

If you replaced "sharp radiating to the back" with "epigastric burning radiating up to the center of the chest, feels like indigestion", would you still have treated? What about transient "funny feeling" that the patient cannot qualify or quantify? Equal arguments could be made for being as good (or better) for your 21 year old's atypical ACS. But that doesn't mean you would treat it as such.

Hey it's tough, just saying with what if given (and not actually being there assessing the patient) I would not have done what you did.

[medic5587]

My differential pre-hospital diagnosis.

With the s/sx as presented.

1.) near syncope or faint feeling with exsertion

2.) stabbing chest pain

3.) c/p radiates to the back

4.) tachycardia (un-changed at rest or on your arrival)

5.) cough

6.) ecg changes

7.) pt takes oral contraceptives

My opinion based on the scenario presented: Pulmonary emboli

[ERDoc]

My differential pre-hospital diagnosis.

With the s/sx as presented.

1.) near syncope or faint feeling with exsertion

2.) stabbing chest pain

3.) c/p radiates to the back

4.) tachycardia (un-changed at rest or on your arrival)

5.) cough

6.) ecg changes

7.) pt takes oral contraceptives

My opinion based on the scenario presented: Pulmonary emboli

Pain from PEs generally do not resolve until the lungs has infarcted. I think PE is something to think about, but highly unlikely in this situation. With a presentation like this in the ER, I wouldn't even work it up. Clinically, my suspicion is almost none.