A 43-year-old man comes to the hospital with chest pain described as dull and nonradiating. The patient has never had chest pain before but has had occasional episodes of dyspnea and coughing in the past. His medical history is significant for diet-controlled diabetes, allergic rhinitis, and childhood eczema. The patient's family history is significant for prostate cancer in his father and rheumatoid arthritis in his mother. He currently takes no medications and does not smoke or consume alcohol. Initial ECG shows ST depression in lateral leads, but cardiac markers show no evidence of acute myocardial infarction. The patient is admitted for further evaluation and is treated with aspirin, clopidogrel, low-molecular-weight heparin, metoprolol, and lisinopril. The next morning, he has shortness of breath and a dry cough but no chest pain. His temperature is 37.2 C (99 F), blood pressure is 122/70 mm Hg, pulse is 63/min, and respirations are 22/min. Oxygen saturation is 95% on room air. Physical examination shows prolonged expiration with bilateral wheezes. There are no crackles. Cardiac examination is normal, and jugular venous pressure is normal. Which of the following is most likely responsible for this patient's current respiratory symptoms?

Question

A 43-year-old man comes to the hospital with chest pain described as dull and nonradiating.  The patient has never had chest pain before but has had occasional episodes of dyspnea and coughing in the past.  His medical history is significant for diet-controlled diabetes, allergic rhinitis, and childhood eczema.  The patient's family history is significant for prostate cancer in his father and rheumatoid arthritis in his mother.  He currently takes no medications and does not smoke or consume alcohol.  Initial ECG shows ST depression in lateral leads, but cardiac markers show no evidence of acute myocardial infarction.  The patient is admitted for further evaluation and is treated with aspirin, clopidogrel, low-molecular-weight heparin, metoprolol, and lisinopril.  The next morning, he has shortness of breath and a dry cough but no chest pain.  His temperature is 37.2 C (99 F), blood pressure is 122/70 mm Hg, pulse is 63/min, and respirations are 22/min.  Oxygen saturation is 95% on room air.  Physical examination shows prolonged expiration with bilateral wheezes.  There are no crackles.  Cardiac examination is normal, and jugular venous pressure is normal.  Which of the following is most likely responsible for this patient's current respiratory symptoms?

Quizplus · Accepted Answer

This patient was initially admitted for chest pain (possibly unstable angina given the ST depressions on ECG) and appropriately treated (eg, antiplatelet therapy, beta blocker and ACE inhibitor therapy, anticoagulation therapy). His subsequent acute-onset dyspnea with wheezing and prolonged expiration on the second day of hospitalization indicates bronchoconstriction. Given his history of allergic rhinitis and eczema and his prior intermittent episodes of dyspnea and coughing, the patient likely has undiagnosed asthma that is now exacerbated by aspirin or possibly beta blocker therapy. Aspirin is a common trigger for bronchoconstriction in patients with asthma, especially those with concurrent chronic rhinitis and nasal polyps. Nonselective beta blockers (eg, propranolol, nadolol, sotalol, timolol) act on β1 and β2 receptors and often trigger bronchoconstriction in patients with underlying asthma. Cardioselective beta blockers (eg, metoprolol, atenolol, bisoprolol, nebivolol) act predominantly on β1 receptors and are generally considered safe in patients with mild-to-moderate asthma. However, all beta blockers can trigger bronchoconstriction, especially when administered in large doses. This medication-triggered bronchoconstriction can lead to a cough. In addition, ACE inhibitors (eg, lisinopril) can cause dry cough through increased levels of circulating bradykinin and resultant bronchial irritation. Onset of the cough can occur soon after ACE inhibitor initiation (as is likely the case in this patient) or can be delayed (eg, months); it is not affected by underlying asthma. (Choice B) Acute bronchitis is usually caused by a viral upper respiratory infection (URI) and characterized by persistent cough, sometimes with sputum production. The timing of symptom onset (1-2 days after new medications) and lack of other symptoms suggestive of URI (eg, rhinorrhea) make acute bronchitis less likely. (Choice C) Acute pericarditis is characterized by sharp, pleuritic chest pain that is often relieved with leaning forward. A pericardial friction rub may be present on cardiac auscultation. Dyspnea is less common, and bronchoconstriction is not typical. (Choice D) Physical examination in patients with pleural effusion shows dullness to percussion of the chest wall, decreased breath sounds, and decreased movement of the ipsilateral chest wall. (Choice E) Patients with pulmonary embolism can have chest pain, dyspnea, and/or tachypnea. Wheezing and prolonged expiration are possible but not typical. (Choice F) Recurrent myocardial ischemia can cause dyspnea and wheezing if it leads to impaired left ventricular function with resulting pulmonary edema. Such patients would have bibasilar rales and may have jugular venous distension (JVD). (Choice G) Patients with right ventricular myocardial infarction usually present with hypotension, JVD, and clear lung fields, usually in the setting of inferior wall myocardial infarction. Educational objective: Aspirin and beta blockers are common medications that can trigger bronchoconstriction in patients with asthma. Short-term use of cardioselective beta blockers is usually safe in patients with mild-to-moderate asthma, but all beta blockers should be used with caution. References: Aspirin-exacerbated respiratory disease: burden of disease. (http://www.ncbi.nlm.nih.gov/pubmed/22525387) Cardioselective beta-blocker use in patients with reversible airway disease. (http://www.ncbi.nlm.nih.gov/pubmed/11406056)

A 43-Year-Old Man Comes to the Hospital with Chest Pain