- Email: [email protected]
A 57-Year-Old Woman with Atypical Chest Pain
CASE REVIEW
A 57-YEAR-OLD WOMAN WITH ATYPICAL CHEST PAIN Author: Karen M. Poor, RN, MN, CEN, CCNS, Woodbury, MN Section Editor: Laura M. Criddle, PhD, RN, CEN, CCNS, FAEN
Earn Up to 8.5 CE Hours. See page 518. 57-year-old woman presented to the emergency department after experiencing sudden-onset chest pain while driving. On admission, she was symptomatic with heavy, non-pleuritic, mid-sternal pain that radiated to her left neck and shoulder. She was very anxious but had no dizziness, nausea, diaphoresis, leg symptoms, or history of recent illness. During a cardiac stress test sometime in the past, the patient had complained of similar but less severe symptoms. She also had a history of cardiac ablation therapy for an unknown rhythm disturbance. Her only cardiac risk factor was morbid obesity, and her medical history included chronic pain, anxiety, and panic attacks. At the time of ED arrival, the patient’s 12-lead electrocardiogram (ECG) was interpreted as normal and her blood pressure was 160/90 mm Hg. The pain had waxed and waned, but after 3 doses of sublingual nitroglycerin, it was only slightly decreased. Morphine sulfate and lorazepam were administered with no change in symptoms. Twenty minutes after arrival, the patient had an increase in pain and a repeat ECG showed ST-segment elevation in leads V1 through V6. She was emergently transported to the interventional cardiology suite. A coronary angiogram showed a long segment of dissection in the mid left anterior descending coronary artery with moderate atherosclerosis of her obtuse marginal and right posterior descending arteries. The woman underwent successful stenting, and she had no adverse sequelae.
A
Karen M. Poor, Member, ENA, is Clinical Nurse Specialist, Emergency Departments, HealthEast System, Woodbury, MN. For correspondence, write: Karen M. Poor, RN, MN, CEN, CCNS, Emergency Department, 1925 Woodwinds Dr, Woodbury, MN 55125; E-mail: [email protected]. J Emerg Nurs 2011;37:487-8. Available online 16 September 2010. 0099-1767/$36.00 Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.07.014
September 2011
VOLUME 37 • ISSUE 5
Discussion
Spontaneous coronary artery dissection (SCAD) is an uncommon pathologic condition. Approximately 278 case reports appeared in the literature before 2000. Although the actual number of patients who have coronary artery dissection is unknown, the SCAD mortality rate is estimated to be about 70% in untreated patients. More than 70% of patients are female, though SCAD has been reported in older men with atherosclerotic disease.1 The mean age at onset in women is 35 to 40 years, although there are reports of SCAD in patients ranging from 28 to 71 years old. Dissection occurs when there is separation of the coronary artery’s tunica intima from the tunica media. The resulting hematoma narrows the lumen, disrupting coronary blood flow and potentially rupturing the vessel. Approximately 70% of cases involve the left main or anterior descending coronary arteries. In women dissection predominantly occurs in the left coronary artery; men tend to have right coronary involvement. Several case reports describe multiple areas of dissection.2 Approximately 30% of coronary artery dissections occur in peripartum or postpartum women. Those in the second post-delivery week are at highest risk.2,3 Blood vessel changes related to sex hormone levels—combined with pregnancy-associated increases in circulating volume and myocardial workload—can produce coronary artery– shearing injuries.2 SCAD development may also be linked to menstruation, menopause, and oral contraceptive use. In men atherosclerosis tends to precipitate SCAD. When an atheroma ruptures, the tear can cause dissection of the coronary artery.2 There have also been many reports of idiopathic SCAD occurring in young, previously healthy individuals. SCAD has been associated with episodes of hemodynamic stress such as moving heavy objects, skiing, wrestling, sexual intercourse, and weight lifting.3 Medical conditions linked to SCAD involve vascular disorders and collagen metabolism defects including Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, cystic medial necrosis, neurofibromatosis, renal disease, hypothyroidism, inflammatory bowel disease, and antiphospholipid syndrome. Other conditions associated with SCAD are pel-
WWW.JENONLINE.ORG
487
CASE REVIEW/Poor
vic radiation and chemotherapy, cocaine use, sleep deprivation, and blunt chest trauma.2 SCAD patients can present with symptoms that mimic acute coronary syndromes. Presenting findings include chest pain described as acute in onset, which is sometimes waxing and waning in nature, similar to stable angina. Other findings reported are new-onset atrial fibrillation and symptoms of acute aortic dissection. Emergency nurses need to consider the possibility of coronary artery dissection, especially in women presenting with chest pain who are pregnant (or <12 weeks post partum) and in young women with chest pain and no identifiable cardiac risk factors. Close attention should be paid to the patient’s menstrual and oral contraceptive use status. In the premenopausal woman, a urine test to identify pregnancy is prudent. Patients aged over 45 years who present with chest pain or other acute coronary syndrome symptoms are generally assigned an Emergency Severity Index acuity of 2. Head-to-toe assessment should include general appearance, cardiac rhythm, heart and lung sounds, and vital signs. Routine diagnostic studies, such as 12-lead ECG, cardiac biomarker levels, and chest radiography, are part of any cardiac workup. The ECG in the SCAD patient may show signs of myocardial ischemia or injury if he or she has ongoing chest pain. Patients should be monitored for dysrhythmias and ST-segment elevation. Continuous 12-lead monitoring is optimal, but if it is not available, the V lead should be placed in the V2 or V3 position to monitor left coronary circulation. Lead II monitors ST elevation in the right coronary circulation. A definitive diagnosis of SCAD is made with coronary angiography, although intravascular ultrasound and computed tomography angiography may suggest the diagnosis. Most ED chest pain protocols call for administration of oxygen, sublingual nitroglycerin, and an intravenous narcotic analgesic if nitroglycerin does not resolve the pain. Nitroglycerin, however, is ineffective at relieving the pain of dissection. There are no contraindications to administering heparin to the SCAD patient. Thrombolytic use is controversial; the drug can open the coronary artery lumen, but it may also cause hematoma expansion, extending the dissection.2 In cases of limited, stable, asymptomatic dissections, patients managed with an antiplatelet agent, β-blocker, nitrate, and antithrombin medication have generally positive outcomes.3 Intracoronary stenting is recommended for larger dissections, those occurring in vital portions of a coronary artery, and patients who continue to have symptoms of cardiac ischemia.2 Intracoron-
488
JOURNAL OF EMERGENCY NURSING
ary stenting is not recommended for left main coronary artery dissections because of the potential for complications. Coronary artery bypass grafting is the treatment of choice for left main coronary artery dissections, multiple dissections, complications arising from coronary angioplasty, and ischemia that has not improved with medical or interventional management.4 Patients who are diagnosed early have a survival rate as high as 95%.2 Unfortunately, some reports indicate that 50% of SCAD patients will have recurrent dissection within 2 months.5 Predictors of death related to SCAD are female gender, advanced age, and failure to receive treatment.1 Summary
SCAD is a rare but potentially lethal pathologic condition. Emergency care providers should consider SCAD in peripartum or postpartum patients, patients who have hormonal changes, and patients recently involved in strenuous exercise. Cardiac catheterization provides a definitive diagnosis. In treated patients the chance of survival is excellent. Available treatment options include medical management, intracoronary stenting, and coronary artery bypass grafting. REFERENCES 1. Thompson EA, Ferrais SE, Gress T, et al. Gender differences and predictors of mortality in spontaneous coronary artery dissection: a review of reported cases. J Invasive Cardiol. 2005;17(1):59. 2. Tanis W, Stella P, Pijlman A, Kirkels J, Peters R, DeMan F. Spontaneous coronary artery dissection: current insights and therapy. Neth Heart J. 2008;16(10):344-9. 3. Kamran M, Gupta A, Bogal M. Spontaneous coronary artery dissection: Case series and review. J Invasive Cardiol. 2008;20(10):553-9. 4. Vanzetto G, Berger-Coz E, Barone-Rochette G, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients. Eur J Cardiothorac Surg. 2009;35(2):250-4. 5. Kamineni R, Ashish S, Alpert J. Spontaneous coronary artery dissection: report of two cases and a 50-year review of the literature. Cardiol Rev. 2002;10(5):279-84.
This section features actual emergency situations with particular educational value for the emergency nurse. Contributions (3 to 5 typed, double-spaced pages) should include a case summary focused on the emergency care phase, accompanied by pertinent case commentary. Submissions to this column are encouraged and may be sent to Laura M. Criddle, PhD, RN, CEN, CCNS, FAEN http://ees.elsevier.com/jen
VOLUME 37 • ISSUE 5
September 2011
A 57-YEAR-OLD WOMAN WITH ATYPICAL CHEST PAIN Author: Karen M. Poor, RN, MN, CEN, CCNS, Woodbury, MN Section Editor: Laura M. Criddle, PhD, RN, CEN, CCNS, FAEN
Earn Up to 8.5 CE Hours. See page 518. 57-year-old woman presented to the emergency department after experiencing sudden-onset chest pain while driving. On admission, she was symptomatic with heavy, non-pleuritic, mid-sternal pain that radiated to her left neck and shoulder. She was very anxious but had no dizziness, nausea, diaphoresis, leg symptoms, or history of recent illness. During a cardiac stress test sometime in the past, the patient had complained of similar but less severe symptoms. She also had a history of cardiac ablation therapy for an unknown rhythm disturbance. Her only cardiac risk factor was morbid obesity, and her medical history included chronic pain, anxiety, and panic attacks. At the time of ED arrival, the patient’s 12-lead electrocardiogram (ECG) was interpreted as normal and her blood pressure was 160/90 mm Hg. The pain had waxed and waned, but after 3 doses of sublingual nitroglycerin, it was only slightly decreased. Morphine sulfate and lorazepam were administered with no change in symptoms. Twenty minutes after arrival, the patient had an increase in pain and a repeat ECG showed ST-segment elevation in leads V1 through V6. She was emergently transported to the interventional cardiology suite. A coronary angiogram showed a long segment of dissection in the mid left anterior descending coronary artery with moderate atherosclerosis of her obtuse marginal and right posterior descending arteries. The woman underwent successful stenting, and she had no adverse sequelae.
A
Karen M. Poor, Member, ENA, is Clinical Nurse Specialist, Emergency Departments, HealthEast System, Woodbury, MN. For correspondence, write: Karen M. Poor, RN, MN, CEN, CCNS, Emergency Department, 1925 Woodwinds Dr, Woodbury, MN 55125; E-mail: [email protected]. J Emerg Nurs 2011;37:487-8. Available online 16 September 2010. 0099-1767/$36.00 Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.07.014
September 2011
VOLUME 37 • ISSUE 5
Discussion
Spontaneous coronary artery dissection (SCAD) is an uncommon pathologic condition. Approximately 278 case reports appeared in the literature before 2000. Although the actual number of patients who have coronary artery dissection is unknown, the SCAD mortality rate is estimated to be about 70% in untreated patients. More than 70% of patients are female, though SCAD has been reported in older men with atherosclerotic disease.1 The mean age at onset in women is 35 to 40 years, although there are reports of SCAD in patients ranging from 28 to 71 years old. Dissection occurs when there is separation of the coronary artery’s tunica intima from the tunica media. The resulting hematoma narrows the lumen, disrupting coronary blood flow and potentially rupturing the vessel. Approximately 70% of cases involve the left main or anterior descending coronary arteries. In women dissection predominantly occurs in the left coronary artery; men tend to have right coronary involvement. Several case reports describe multiple areas of dissection.2 Approximately 30% of coronary artery dissections occur in peripartum or postpartum women. Those in the second post-delivery week are at highest risk.2,3 Blood vessel changes related to sex hormone levels—combined with pregnancy-associated increases in circulating volume and myocardial workload—can produce coronary artery– shearing injuries.2 SCAD development may also be linked to menstruation, menopause, and oral contraceptive use. In men atherosclerosis tends to precipitate SCAD. When an atheroma ruptures, the tear can cause dissection of the coronary artery.2 There have also been many reports of idiopathic SCAD occurring in young, previously healthy individuals. SCAD has been associated with episodes of hemodynamic stress such as moving heavy objects, skiing, wrestling, sexual intercourse, and weight lifting.3 Medical conditions linked to SCAD involve vascular disorders and collagen metabolism defects including Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, cystic medial necrosis, neurofibromatosis, renal disease, hypothyroidism, inflammatory bowel disease, and antiphospholipid syndrome. Other conditions associated with SCAD are pel-
WWW.JENONLINE.ORG
487
CASE REVIEW/Poor
vic radiation and chemotherapy, cocaine use, sleep deprivation, and blunt chest trauma.2 SCAD patients can present with symptoms that mimic acute coronary syndromes. Presenting findings include chest pain described as acute in onset, which is sometimes waxing and waning in nature, similar to stable angina. Other findings reported are new-onset atrial fibrillation and symptoms of acute aortic dissection. Emergency nurses need to consider the possibility of coronary artery dissection, especially in women presenting with chest pain who are pregnant (or <12 weeks post partum) and in young women with chest pain and no identifiable cardiac risk factors. Close attention should be paid to the patient’s menstrual and oral contraceptive use status. In the premenopausal woman, a urine test to identify pregnancy is prudent. Patients aged over 45 years who present with chest pain or other acute coronary syndrome symptoms are generally assigned an Emergency Severity Index acuity of 2. Head-to-toe assessment should include general appearance, cardiac rhythm, heart and lung sounds, and vital signs. Routine diagnostic studies, such as 12-lead ECG, cardiac biomarker levels, and chest radiography, are part of any cardiac workup. The ECG in the SCAD patient may show signs of myocardial ischemia or injury if he or she has ongoing chest pain. Patients should be monitored for dysrhythmias and ST-segment elevation. Continuous 12-lead monitoring is optimal, but if it is not available, the V lead should be placed in the V2 or V3 position to monitor left coronary circulation. Lead II monitors ST elevation in the right coronary circulation. A definitive diagnosis of SCAD is made with coronary angiography, although intravascular ultrasound and computed tomography angiography may suggest the diagnosis. Most ED chest pain protocols call for administration of oxygen, sublingual nitroglycerin, and an intravenous narcotic analgesic if nitroglycerin does not resolve the pain. Nitroglycerin, however, is ineffective at relieving the pain of dissection. There are no contraindications to administering heparin to the SCAD patient. Thrombolytic use is controversial; the drug can open the coronary artery lumen, but it may also cause hematoma expansion, extending the dissection.2 In cases of limited, stable, asymptomatic dissections, patients managed with an antiplatelet agent, β-blocker, nitrate, and antithrombin medication have generally positive outcomes.3 Intracoronary stenting is recommended for larger dissections, those occurring in vital portions of a coronary artery, and patients who continue to have symptoms of cardiac ischemia.2 Intracoron-
488
JOURNAL OF EMERGENCY NURSING
ary stenting is not recommended for left main coronary artery dissections because of the potential for complications. Coronary artery bypass grafting is the treatment of choice for left main coronary artery dissections, multiple dissections, complications arising from coronary angioplasty, and ischemia that has not improved with medical or interventional management.4 Patients who are diagnosed early have a survival rate as high as 95%.2 Unfortunately, some reports indicate that 50% of SCAD patients will have recurrent dissection within 2 months.5 Predictors of death related to SCAD are female gender, advanced age, and failure to receive treatment.1 Summary
SCAD is a rare but potentially lethal pathologic condition. Emergency care providers should consider SCAD in peripartum or postpartum patients, patients who have hormonal changes, and patients recently involved in strenuous exercise. Cardiac catheterization provides a definitive diagnosis. In treated patients the chance of survival is excellent. Available treatment options include medical management, intracoronary stenting, and coronary artery bypass grafting. REFERENCES 1. Thompson EA, Ferrais SE, Gress T, et al. Gender differences and predictors of mortality in spontaneous coronary artery dissection: a review of reported cases. J Invasive Cardiol. 2005;17(1):59. 2. Tanis W, Stella P, Pijlman A, Kirkels J, Peters R, DeMan F. Spontaneous coronary artery dissection: current insights and therapy. Neth Heart J. 2008;16(10):344-9. 3. Kamran M, Gupta A, Bogal M. Spontaneous coronary artery dissection: Case series and review. J Invasive Cardiol. 2008;20(10):553-9. 4. Vanzetto G, Berger-Coz E, Barone-Rochette G, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients. Eur J Cardiothorac Surg. 2009;35(2):250-4. 5. Kamineni R, Ashish S, Alpert J. Spontaneous coronary artery dissection: report of two cases and a 50-year review of the literature. Cardiol Rev. 2002;10(5):279-84.
This section features actual emergency situations with particular educational value for the emergency nurse. Contributions (3 to 5 typed, double-spaced pages) should include a case summary focused on the emergency care phase, accompanied by pertinent case commentary. Submissions to this column are encouraged and may be sent to Laura M. Criddle, PhD, RN, CEN, CCNS, FAEN http://ees.elsevier.com/jen
VOLUME 37 • ISSUE 5
September 2011