What's Your Diagnosis? Managing Acute Cardiac Valvular Emergencies in the ED

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got last month’s case on Management of Allergic Reactions and Anaphylaxis in the Emergency Department correct.

Case Presentation: Managing Acute Cardiac Valvular Emergencies in the Emergency Department

A 65-year-old woman with a history of coronary artery disease presents complaining of chest pain and sudden onset of feeling short of breath…

The patient had presented to the ED the week before with chest pain and was discharged after normal serial cardiac troponins and serial ECGs, and an unremarkable chest radiograph. The patient reports that 1 week ago, she ran out of her aspirin and clopidogrel.
As you enter the room, you note the patient has an increased work of breathing. Vital signs are: heart rate, 105 beats/min; blood pressure, 100/75 mm Hg; respiratory rate, 28 breaths/min; temperature, 37.4°C; and oxygen saturation, 89% on room air.
Your exam is concerning for new-onset heart failure with pulmonary congestion and jugular venous distention. When you auscultate a new cardiac murmur, you are concerned about an ischemia-induced valvulopathy. You consider what would be the best way to manage this patient….

Case Conclusion

You obtained an ECG, which showed T-wave inversions. You ordered an emergent TTE and placed a consult from cardiology. The ultrasound sonographer called you to the bedside to report a possible papillary muscle rupture, causing mitral regurgitation, and you called interventional cardiology for further management of the patient.