A Case of Sudden, Severe Myocardial Dysfunction
Information about a real patient is presented in stages (boldface type) to expert clinicians (Dr James M. Kirshenbaum and Dr Gayle L. Winters), who respond to the information, sharing their reasoning with the reader (regular type). A discussion by the authors follows.
A 44-year-old woman presented to her local emergency room with a 1-day history of nausea, fatigue, and fever of 101°F. At that time, she denied chest pain, dyspnea, cough, orthopnea, or lower-extremity edema. An ECG was reportedly normal, and she was treated with antiemetics and fluids and discharged home. The next day, she developed persistent, aching pain in her chest and jaw and presented to her primary care physician. Her medical history included obesity, depression, hyperlipidemia, and antiphospholipid antibody syndrome (APLAS) initially diagnosed in 1989 when she was 20 years of age complicated by 4 miscarriages, pulmonary emboli, and deep vein thrombosis for which she underwent inferior vena cava filter placement in 1997. She had experienced no thromboembolic events over the next 15 years. Her home medications were rivaroxaban 20 mg daily, aspirin 81 mg daily, furosemide 20 mg daily, simvastatin 20 mg daily, escitalopram 20 mg daily, and omeprazole 20 mg daily. She worked as a nurse and lived with her husband and 4 adopted children. She never smoked. Her mother carried the diagnosis of factor V Leiden. She was scheduled for an elective gastric bypass surgery in 2 days and had been instructed to hold her rivaroxaban for 4 days before surgery; therefore, she stopped anticoagulation 2 days before presentation.
Dr Kirshenbaum: Her initial symptoms are quite nonspecific, with nausea and a low fever suggesting a viral process. However, the subsequent development of chest and jaw pain also raises the possibility of cardiac causes such as an acute coronary syndrome. Myocarditis also often presents with …