Case Background

Our patient is a 56-year-old woman with a chief complaint of nausea and substernal aching of two hours duration.

The patient's symptoms awakened her at 4:00 am. Because of her history of duodenal ulcer with nausea, she took an antacid, but her symptoms increased. She became very frightened, and asked her husband to call 911. The paramedics arrived within ten minutes, and obtained the following additional pertinent history:

Two months ago, the patient was hospitalized for a bleeding duodenal ulcer, and received two transfusions. During the last month, she has had several episodes of substernal discomfort and nausea with exertion, each lasting a few minutes. She rested and took an antacid, and her symptoms resolved.

The patient also has a history of hypertension for many years, and the paramedics identified her medication as a beta blocker. As the paramedics were obtaining her vital signs, her chest aching increased and began to radiate into both arms. The discomfort was unaffected by movement, body position or breathing.

In this urgent situation, the paramedics performed a focused cardiovascular examination. The patient was anxious, diaphoretic and dyspneic. Her blood pressure was 140/110 mmHg in both arms, pulse rate 80 and regular, and respirations 24. Her arterial pulses were normal, and there was no jugular venous distention. On auscultation of the heart and lungs, they found no abnormalities.

Based on the patient's focused history and physical examination, immediate management was undertaken by the paramedics. They placed the patient on an ECG monitor and also obtained a 12-lead electrocardiogram. Nasal oxygen, insertion of a peripheral intravenous line and appropriate drug therapy were also initiated.

The patient was quickly transported to a nearby emergency department, where monitoring and oxygen therapy were continued and appropriate studies were ordered, including another electrocardiogram and cardiac biomarkers of necrosis.

As the patient was being evaluated, further history was obtained in the emergency department from her husband. He said he was very worried about her because she didn't take care of herself. She was overweight, had no exercise program and smoked a package of cigarettes per day for thirty-five years. In addition, she is postmenopausal and her mother died of a heart attack at the age of forty-nine. He took her blood pressure every day and it was 130/80 mmHg while on her medication.