Abstract 1760: Chest Pain in an 89-Year-Old Man: A Different Kind of Broken Heart
An 89 year-old male without prior cardiac history presented with chest pain. He described a sharp, tearing pain radiating from upper back to anterior chest, reaching maximal intensity in seconds and resulting in syncope. An ECG obtained in the emergency room after the pain had resolved revealed sinus rhythm and 5 mm anterolateral ST-segment elevation with reciprocal inferior ST depression. The patient appeared comfortable and examination was notable for systemic hypertension, elevated venous pressure, bibasilar rales, a regular rhythm with S4 gallop, no murmur, and cool extremities. Further history revealed an episode of prolonged chest discomfort several days prior, and subsequent symptoms of malaise. Because of the atypical nature of his presentation, anticoagulation was withheld and a CT angiogram performed while waiting for the on call cardiac catheterization team. This revealed a pericardial effusion and possible ascending aortic dissection. Diagnostic uncertainty remained so the patient underwent cardiac catheterization. This demonstrated no aortic dissection, subtotal occlusion of the mid left anterior descending coronary artery, and elevated intracardiac filling pressures. Echocardiography revealed a small apical pericardial effusion, but no discontinuity of myocardium was found. Contrast ventriculography showed apical LV aneurysmal dilatation and dyskinesis, LVEF of 30%, and active extravasation of contrast into a loculated apical pericardial effusion, which was diagnostic for contained LV free wall rupture. Because the infarct likely occurred several days prior, and the rupture was acute, anticoagulation was avoided and percutaneous coronary intervention deferred. The patient was managed with aggressive heart failure therapy, including an intraaortic balloon pump, and offered surgical repair of the ruptured LV. Despite declining surgery, the patient was ultimately weaned to oral medications and discharged home ten days after admission. This case highlights the critical role of taking a careful history when faced with an uncommon presentation of a common problem, as well as the importance of integrating bedside assessment with diagnostic tests, to avoid the pitfall of treating the test result and not the patient.