A 34-year-old man comes to the emergency department due to chest pain that started an hour ago. The pain feels like a "substernal pressure," and the patient rates it as severe. He also feels as though his heart "is racing" but has had no shortness of breath, cough, or fever. The patient's medical history is significant for an appendectomy a year ago. He was seen in the emergency department 4 weeks ago for anxiety and palpitations and 6 weeks ago for chest pain that resolved spontaneously. His father died at age 64 due to "some heart problem," and his mother died of ovarian cancer. On physical examination, the patient appears agitated and is sweating profusely. His blood pressure is 160/110 mm Hg, pulse is 110/min, and respirations are 16/min. His pupils are dilated and reactive to light. No heart murmurs are heard. The abdomen is soft and nontender. ECG shows sinus tachycardia with ST elevations in leads V1-V4. What is the most likely explanation for this patient's symptoms?

Question

A 34-year-old man comes to the emergency department due to chest pain that started an hour ago.  The pain feels like a "substernal pressure," and the patient rates it as severe.  He also feels as though his heart "is racing" but has had no shortness of breath, cough, or fever.  The patient's medical history is significant for an appendectomy a year ago.  He was seen in the emergency department 4 weeks ago for anxiety and palpitations and 6 weeks ago for chest pain that resolved spontaneously.  His father died at age 64 due to "some heart problem," and his mother died of ovarian cancer.  On physical examination, the patient appears agitated and is sweating profusely.  His blood pressure is 160/110 mm Hg, pulse is 110/min, and respirations are 16/min.  His pupils are dilated and reactive to light.  No heart murmurs are heard.  The abdomen is soft and nontender.  ECG shows sinus tachycardia with ST elevations in leads V1-V4.  What is the most likely explanation for this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d17e_d5f4_bc81_ad6f0fc5ce54_MD0003_00 This patient has severe substernal chest pain and ST-segment elevation in leads V1-V4, consistent with acute anterior ST-elevation myocardial infarction (STEMI). The associated clinical findings-psychomotor agitation, dilated pupils, tachycardia, and hypertension-along with the history of multiple recent emergency department visits for chest pain and palpitations in a young and otherwise healthy patient are suggestive of acute cocaine intoxication. Cocaine acts as a sympathomimetic agent that induces coronary vasoconstriction, promotes thrombus formation, and increases the risk of myocardial ischemia and infarction by causing increased myocardial oxygen demand. Patients with acute cocaine intoxication should initially be treated with intravenous benzodiazepines to alleviate psychomotor agitation and sympathomimetic effects (eg, tachycardia, hypertension). Those with acute coronary syndrome (eg, STEMI) are managed with antiplatelet therapy, nitrates, and percutaneous coronary intervention if indicated. Beta blockers are sometimes avoided due to the theoretical risk of unopposed cocaine-induced alpha agonist activity and resultant worsening vasoconstriction. (Choice A) ECG in acute pericarditis typically shows diffuse (rather than regional) ST-segment elevations and PR-segment depression across the limb and precordial leads. acute pericarditis (Choices B and D) Cocaine use can lead to pulmonary infarction (eg, pleuritic chest pain, dyspnea, hypoxemia) and, rarely, can cause aortic dissection (chest pain radiating to the back, blood pressure differential); however, this patient's clinical presentation and ECG changes are consistent with acute STEMI. (Choice C) Coronary atherosclerosis is the most common cause of acute coronary syndrome in older patients with coronary risk factors. Psychomotor agitation and pupillary dilation in an otherwise healthy young patient are more suggestive of acute cocaine intoxication. (Choice E) Stress-induced (Takotsubo) cardiomyopathy (apical ballooning syndrome, "broken heart" syndrome) refers to a transient systolic dysfunction of apical and/or mid segments of the left ventricle with hyperkinesis of the basal segments, causing a "balloon-like" appearance of the left ventricle in systole. It is seen predominantly in older adults in response to intense physical or emotional stress or acute medical illness (eg, unexpected death of a relative, grave medical diagnosis, arguments, significant loss). Educational objective: Cocaine acts as a sympathomimetic agent that leads to hypertension, tachycardia, pupillary dilation, and psychomotor agitation; causes coronary vasoconstriction; promotes thrombus formation; and increases the risk of myocardial ischemia and infarction. References: Cocaine cardiovascular toxicity. (http://www.ncbi.nlm.nih.gov/pubmed/16144174)

A 34-Year-Old Man Comes to the Emergency Department Due to Chest