A 36-year-old woman comes to the emergency department due to chest pain that started suddenly while she was shopping at the mall. She also has shortness of breath, palpitations, and diaphoresis. The pain is retrosternal and radiates to the left arm. There are no aggravating or relieving factors. She appears to be in mild discomfort. On review of systems, the patient reports having had a runny nose, sore throat, and dry cough for the past 3 days. Her other medical problems include panic attacks treated with paroxetine and dysfunctional uterine bleeding treated with estrogen. Family history is significant for her father's sudden death at age 44 from a heart attack. The patient has a 15-pack-year smoking history. Her blood pressure is 144/90 mm Hg and pulse is 104/min and regular. Her body mass index is 29 kg/m². Which of the following is the most appropriate initial therapy for this patient?

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11ec25c8_d185_b3ca_bc81_25faed01baf9_MD0003_00 This patient's presentation and risk factors (smoking, family history, estrogen therapy) are concerning for acute coronary syndrome (ACS). Retrosternal chest pain radiating to the left arm with associated diaphoresis, nausea, and/or vomiting usually (but not always) suggests ACS. Regardless of the etiology, all patients who come to the emergency department with chest pain should have a focused history, physical examination, and assessment of vital signs. Unstable patients with abnormalities in airway, breathing, circulation, and/or life-threatening arrhythmias should be stabilized and assessed for underlying causes (eg, pulmonary embolism [PE], pericarditis, aortic dissection). Stable patients should receive oxygen, intravenous access, ECG, and chest x-ray. Patients with possible ACS (and low risk for aortic dissection) should receive aspirin as soon as possible. Aspirin inhibits thromboxane A2 production to exert significant antiplatelet effects. It significantly reduces the rate of myocardial infarction (MI), stroke, and overall mortality in ACS. Patients with ECG findings of ACS should be treated appropriately (eg, heparin). Those with nondiagnostic chest x-ray and ECG should have further workup for possible causes (eg, PE, acute pericarditis). (Choices A and F) Acetaminophen and oxycodone can be given for musculoskeletal chest pain. This patient has no history of recent trauma or mention of reproducible pinpoint tenderness on chest examination to suggest a musculoskeletal etiology. (Choice C) Heparin is used for patients with MI (positive cardiac markers or ST elevation on ECG) or those in whom there is a high probability of PE or in whom PE has been confirmed. Based on her Wells score, PE is unlikely in this patient. Given her presentation and risk factors, ACS should be ruled out first (eg, ECG). In addition, aspirin is given initially before heparin in ACS. Wells score (Choice D) Ibuprofen is used in the treatment of pericarditis. Although pericarditis is possible with the patient's prior history of recent upper respiratory tract infection, ACS must be evaluated first given her high risk. Chest pain in acute pericarditis improves with leaning forward. (Choice E) Lorazepam is a benzodiazepine used for chest pain stemming from an acute panic attack. Although this patient has a history of panic attacks, her current history is more concerning for ACS, which should be ruled out first. Educational objective: Patients presenting to the emergency department with chest pain and suspected acute coronary syndrome (ACS) should be administered aspirin as soon as possible. Early antiplatelet therapy with aspirin reduces the rate of myocardial infarction and overall mortality in patients with ACS. References: Emergency department and office-based evaluation of patients with chest pain. (http://www.ncbi.nlm.nih.gov/pubmed/20194155)

A 36-Year-Old Woman Comes to the Emergency Department Due to Chest