Cardio Case Challenge: Syncope in a 53-Year-Old Woman With Dyspnea and Morning Chest Pain

Maria Cristina Bravi, MD, PhD


April 18, 2022

Physical Examination and Workup

The physical examination reveals a normal heart rate and regular rhythm, normal oxygenation, an elevated blood pressure (170/90 mm Hg) and obesity (body mass index of 35; central obesity with an abdominal circumference of 110 cm is noted). Jugular venous distention is estimated at 6-8 cm; however, this is difficult to assess because of the patient's obesity.

Carotid artery bruits are absent. Her lungs are clear to auscultation bilaterally, with normal respiratory effort and good air movement throughout the lung fields. The cardiac examination demonstrates a regular rate and rhythm, with a normal S1 and a physiologically split S2 without murmurs, rubs, or gallops. The abdomen is soft and nontender. Her peripheral pulses are 2+ and symmetric in all 4 extremities. The lower extremities are warm, well perfused, and without edema. The neurologic examination shows the patient to be alert and oriented to person, place, and time, without any focal deficits.

The rest of her examination is unremarkable. Chest radiography reveals a dilated aortic arch.

Laboratory investigations reveal a normal complete blood cell count. Serial measurements of her cardiac biomarkers remain normal. Liver function tests are performed, including: aspartate aminotransferase (AST), 112 IU/L (reference range 3-45 IU/L); alanine aminotransferase (ALT), 87 IU/L (reference range 5-35 IU/L); alkaline phosphatase, 384 IU/L (reference range 10-95 IU/L); and gamma-glutamyl transferase, 227 IU/L (reference value < 45 IU/L). Despite physician recommendations for admission and further evaluation, the patient signs out of the ED against medical advice and returns home with her husband.

Three days later, the patient suffers cardiac arrest while at a shopping mall. EMS arrives at the scene and, a few minutes later, they obtain a rhythm strip that demonstrates ventricular fibrillation. Cardiopulmonary resuscitation (CPR) is initiated and the patient is electrically shocked into a sinus rhythm. She slowly regains consciousness after cardioversion. Upon arrival to the ED, the patient is placed on a cardiac monitor. A 12-lead ECG reveals a normal rhythm and normal ST segments and T waves.

No evidence suggests a prolonged QTc or hypertrophy. A bedside echocardiogram demonstrates no wall motion abnormalities and a preserved ejection fraction with mild left ventricular hypertrophy. A cardiology service consultation is obtained and the patient is admitted to the cardiac care unit in anticipation of coronary angiography and left ventriculography. Early in the morning 2 days later, while on cardiac monitoring, the patient experiences another short episode of chest pain that evolves into a cardiac arrest. She spontaneously regains circulation after 2 minutes of CPR.


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