Asma

The

n e w e ng l a n d j o u r na l

of

m e dic i n e

clinical problem-solving

A Change of Heart
Thomas T. Tsai, M.D., M.Sc., Brahmajee K. Nallamothu, M.D., M.P.H., Abhiram Prasad, M.D., Sanjay Saint, M.D., M.P.H., and Eric R. Bates, M.D.
In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to theinformation, sharing his or her reasoning with the reader (regular type). The authors’ commentary follows.

From the Denver Veterans Affairs (VA) Medical Center and the Department of Internal Medicine, University of Colorado — both in Denver (T.T.T.); the Health Services Research and Development Center of Excellence, Ann Arbor VA Medical Center (B.K.N., S.S.); and the Department of InternalMedicine, University of Michigan (B.K.N., S.S., E.R.B.) — both in Ann Arbor; and the Division of Cardiovascular Diseases and Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN (A.P.). Address reprint requests to Dr. Tsai at the University of Colorado Denver, Cardiology Section (111B), 1055 Clermont St., Denver, CO 80220, or at thomas.tsai@va.gov. N Engl J Med 2009;361:1010-6.Copyright © 2009 Massachusetts Medical Society.

A 57-year-old teacher with a history of hypertension presented to an urgent care center with nonradiating chest pressure and light-headedness. The chest pressure had begun soon after she arrived at work that morning, when she was physically threatened by a parent of one of her fifth-grade students. Her symptoms improved with rest immediatelyafter the event but then worsened by the end of the day. When she returned home, her husband took her blood pressure and noted systolic values ranging from 80 to 90 mm Hg, with a heart rate of approximately 110 beats per minute. Her symptoms and blood pressure did not improve by drinking fluids, which prompted her visit to the center. Chest pressure may suggest any of several disease processes,ranging from benign conditions to life-threatening emergencies. In the presence of hypotension, the initial evaluation must focus on ruling out the latter, which include an acute coronary syndrome, aortic dissection, pulmonary embolism, esophageal rupture, and tension pneumothorax. Additional cardiac disorders such as myocarditis or pericarditis are also consistent with this patient’s presentation.Noncardiac disorders that can cause chest pressure include gastroesophageal reflux disease, peptic ulcer disease, costochondritis, herpes zoster infection, pleuritis, and panic attack; however, none of these would be expected to cause hypotension. The patient had a history of well-controlled hypertension but no other medical problems. Her only medication was lisinopril, 5 mg daily. There was nofamily history of early coronary artery disease or sudden cardiac death. She had smoked approximately five cigarettes daily for 30 years, rarely drank alcohol, and reported no illicit-drug use. On initial evaluation, the patient reported slight chest pressure but was not in acute distress. She was afebrile. Her blood pressure was 83/50 mm Hg, her heart rate was 110 beats per minute, and her respiratoryrate was 14 breaths per minute. Pulse oximetry revealed an oxygen saturation of 99% while she was breathing 2 liters of oxygen through a nasal cannula. Her neck was supple, and jugular venous pressure was not elevated. Auscultation of the chest revealed a loud, crescendo systolic murmur, best heard at the right upper sternal border, but her lungs were clear. The abdominal examination wasunremarkable. Her lower extremities were warm, with symmetric distal pulses, and showed no edema. The remainder of the physical examination was normal. This patient’s hypotension and tachycardia are worrisome. They suggest the early stage of shock and thus warrant urgent diagnostic testing and management, particu-

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n engl j med 361;10

nejm.org

september 3, 2009

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