A 25 year old female with a history of lupus presents with chest pain and shortness of breath. Her vitals are significant for tachycardia and are otherwise within normal limits. Her initial EKG is shown below:
The STEMI phone is contacted. Prior to cath lab activation, cardiology recommends a bedside echocardiogram which demonstrates the following:
Cardiology performed echocardiogram re-demonstrates a circumferential pericardial effusion without regional wall motion abnormalities or tamponade physiology. The cath lab was not activated, there was no elevation in troponins, and the patient was ultimately diagnosed with acute pericarditis.
Diagnostic Criteria for Acute Pericarditis (requires 2 of the following) |
Characteristic chest pain (sharp or pleuritic, improved sitting up and leaning forward, worse lying down) |
Pericardial friction rub |
New or worsening pericardial effusion |
Suggestive EKG changes (diffuse ST segment elevations) |
- Spontaneous Coronary Artery Dissection (SCAD) is a life threatening process involving a tear within the coronary arterial wall.
- SCAD predominantly affects young (< 50) women especially during pregnancy and post-partum periods. It can appear identical to a STEMI on EKG despite “non-occluded” coronary vessels. It is commonly associated with a rise in cardiac enzymes and regional wall motion abnormalities on echocardiogram. It is definitively diagnosed via coronary angiography. Treatment will vary based on high vs low risk features.
References:
Diercks DB, Hollander JE, Chang A. Acute Coronary Syndromes. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.
Kim ESH. Spontaneous Coronary-Artery Dissection. N Engl J Med. 2020 Dec 10;383(24):2358-2370.
Ornato, J. P., Ou, N., Radford, M. J., Tamis-Holland, J. E., Tommaso, C. L., … Zhao, D. X. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61(4), e78–e140. https://doi.org/10.1016/j.jacc.2012.11.019
Whelan LJ. Comorbid Disorders in Pregnancy. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.