Case 51: Chest Pain

Case 51: Chest Pain

History
A 62-year-old man is admitted to hospital with chest pain. The pain is in the centre of the chest
and has lasted for 3 h by the time of his arrival in the emergency department. The chest pain
radiated to the jaw and left shoulder. He felt sick at the same time. He has a history of chest
pain on exercise, which has been present for 6 months. He has smoked 10 cigarettes daily for
40 years and does not drink alcohol. He has been treated with aspirin and with beta-blockers
regularly for the last 2 years and has been given a glyceryl trinitrate spray to use as needed.
This turns out to be two or three times a week. His father died of a myocardial infarction at age
66 years, and his 65-year-old brother had a coronary artery bypass graft 4 years ago.
He has no other previous medical history. He works as a security guard.
Examination
He is sweaty and in pain but has no abnormalities in the cardiovascular or respiratory sys-
tems. His blood pressure is 138/82 mmHg, and his pulse rate is 110/min and regular.

Investigations

His electrocardiogram (ECG) is shown in Figure 51.1.

I aVR V1 V4

aVL V2 V5
II

aVF V3 V6
III

II
Figure 51.1 Electrocardiogram.
He was given analgesia and underwent emergency primary angioplasty and stenting to a
severe left anterior coronary artery lesion, and clopidrogel was added to his treatment. His
pain settled and after two days he began to mobilize. On the fourth day after admission, he
became more unwell.
On examination, now his jugular venous pressure is raised to 6 cm above the manubrioster-
nal angle. His blood pressure is 102/64 mmHg; pulse rate is 106/min and regular. His tem-
perature is 37.8°C. On auscultation of the heart, there is a loud systolic murmur heard all
over the praecordium. In the respiratory system, there are late inspiratory crackles at the
lung bases, and these are heard up to the midzones. There are no new abnormalities to find
elsewhere on examination. His chest X-ray is shown in Figure 51.2.

Questions
• What is the likely diagnosis?
• How might this be confirmed?

Figure 51.2 Chest X-ray.

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ANSWER 51
This 62-year-old man had an anteroseptal myocardial infarction, indicated by Q-waves in
V2 and V3 and raised ST segments in V2, V3, V4 and V5. He became unwell suddenly
4 days later having had no initial problems. The late inspiratory crackles are typical of pul-
monary oedema, and the chest X-ray confirms this, showing hilar flare with some alveolar
filling, Kerley B lines at the lung bases and blunting of the costophrenic angles with small
pleural effusions.
The problems likely to occur at this time and produce shortness of breath are a further myo-
cardial infarction, arrhythmias, rupture of the chordae tendinae of the mitral valve, perfo-
ration of the intraventricular septum or even the free wall of the ventricle, and pulmonary
emboli. The first four of these could produce pulmonary oedema and a raised jugular venous
pressure, as in this man. Pulmonary embolism would be compatible with a raised jugular
venous pressure but not the findings of pulmonary oedema on examination and X-ray.
Acute mitral regurgitation from chordal rupture and ischaemic perforation of the interven-
tricular septum both produce a loud pansystolic murmur. The site of maximum intensity of
the murmur may differ, being apical with chordal rupture and at the lower left sternal edge
with ventricular septal defect, but this differentiation may not be possible with a loud mur-
mur. The differentiation can be made by echocardiography.
The management of acute ventricular septal defect or chordal rupture would be similar and
should involve consultation with the cardiac surgeons. When these lesions produce haemo-
dynamic problems, as in this case, surgical repair is needed, either acutely if the problem is
very severe or after stabilization with antifailure treatment or even counterpulsation with an
aortic balloon pump. Milder degrees of failure with a pansystolic murmur may occur when
there is ischaemia of the papillary muscles of the mitral valve. This is managed with anti-
failure treatment, not surgical intervention, and can be differentiated by echocardiography.

Key Points

• The cause of breathlessness after myocardial infarction needs careful evaluation.

• The signs of ischaemic ventricular septal defect and mitral regurgitation due to
chordal rupture after myocardial infarction may be very difficult to differentiate.
• Patients with angina or myocardial infarction can also present with the radiating
pain but no central chest pain or with only the cardiac effects and no pain at all.

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