Welcome to this month’s What’s Your Diagnosis Challenge!
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Case Presentation: A 76-year-old woman presents to the ED with chest pain
A 76-year-old woman presents to the ED with chest pain.
She said that for the past month she has been getting short of breath more easily on her daily walks, with occasional discomfort in her chest, requiring her to stop and rest.
Two hours prior to ED arrival, she was doing yard work and developed chest pain that was much more severe. The pain is located in the center of her chest, and she describes it as a ?pressure? sensation. Her only past medical history is hypertension.
In the ED, her vital signs are within normal limits and her exam is unremarkable. Her ECG shows nonspecific ST-segment flattening, and her initial troponin is 0.09 ng/mL (reference range, 0-0.04 ng/mL).
Your intern asks if she can go home since her troponin is low and she looks well…
You agreed with your intern that your first patient was a low-risk NSTE-ACS patient?but she?s not going home with a positive troponin! You treated her with 325 mg oral aspirin, 180 mg oral ticagrelor, and 1 mg/kg subcutaneous enoxaparin. She was given 3 doses of 0.4 mg sublingual nitroglycerin and is now pain-free. Because she had no high-risk features, you told your intern that you would trend her troponins and admit her for medical management of her ACS.
While she was waiting for an inpatient bed, however, her 3-hour troponin came back at 0.74 ng/mL. As her troponin was now above the 99th percentile and had risen 7-fold since arrival, you started to think that she might be a candidate for early catheterization. You consulted cardiology, and they agreed to add her to the schedule for coronary angiography tomorrow morning.
You patted your intern on the back and reminded him that positive troponins are diagnostic of ACS, and mandate further workup even when they?re not that impressive.
Review the issue to find out more about the authors’ recommendation.
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Last Updated on July 9, 2020