A recent case presentation illustrated the increased level of aggression used in diagnosing and treating coronary artery disease The case involved a 48-year-old non-smoker with no risk factors other than “high cholesterol”. The patient had been started on a proton pump inhibitor (a medication used to decrease stomach acid levels) to treat gastroesophageal reflux disease (GERD) 10 days prior to presentation to the emergency room. At the time, the claimant had no angina-type chest pain.
Two days prior to presentation to the emergency room, the patient began to have chest pain when walking up two flights of stairs. He continued to have intermittent exertional chest pain/pressure, and on the day he first sought treatment his angina started after walking a few steps. The patient decided to fly back to Paris from the south of France for treatment, and by the time he presented at a walk-in clinic he had persistent chest pain/pressure at rest.
An 18 lead ECG was obtained. It was read as normal by both the emergency room physician and a cardiologist, although in retrospect there was a questionable isolated microscopic ST elevation in one lead. In other words, nondiagnostic.
On exam, the patient’s vital signs were normal. He had no symptoms of aortic dissection or pericarditis. He described his pain as substernal and radiating backward but it did not migrate. He had no symptoms of heart failure such as rales/rhonchi on auscultation (listening to the chest with a stethoscope.)
The treatment was given intravenous aspirin, clopideogrel (a platelet inhibitor) by mouth, and sublingual nitroglycerin without relief. Intravenous paracetamol and morphine relieved the claimant’s pain.
Because of the patient’s clear progression of exertional to rest chest discomfort, the claimant was sent to the cardiac catheterization laboratory. Note that the decision to go to the Cath Lab was not based on laboratory studies, pain resolution with opiates/paracetamol, or ECG. It was the patient’s history and presentation that pushed the patient down a more acute, aggressive treatment plan.
Per the treating emergency room physician, the patient’s left anterior descending artery was 100% obstructed, and treated with a percutaneous intervention (stenting). Interestingly, the claimants troponin level (a blood test which turns positive when heart muscle is damaged) was normal.
The emergency room physician that treated the patient and I both recall a time when someone with chest pain and a normal ECG was not having coronary pain-particularly in the face of recently diagnosed gastroesophageal reflux disease. Over time, practices have changed, and we are much more aggressive in treating coronary artery disease. Personally I think it’s a Good Thing.