A 64-year-old postmenopausal woman presented to the emergency department at 10 am in the morning with chest pain and shortness of breath of approximately 12 hours duration. Her medical history included right breast invasive ductal carcinoma with bilateral mastectomies in 2015, recently diagnosed bladder cancer with TURBT and intravesical mitomycin C instillation three days prior to current presentation, type 2 diabetes mellitus, hypertension, obstructive sleep apnea, chronic obstructive pulmonary disease, and prothrombin G20210A mutation. She had quit smoking 5 years ago, prior to that she had smoked 2 packs per day for 45 years. She was asymptomatic until about 10 pm the night before presentation, when she developed shortness of breath and sharp pleuritic chest pain while she was lying in bed. The patient reported that her chest pain was located in the substernal region, radiating to the back, aggravated by deep breaths and by lying down, and alleviated by sitting up and leaning forward. She said that she had taken some ibuprofen which had reduced the intensity of pain. She did endorse that she was also experiencing a less prominent pressure like sensation in addition to the sharp pleuritic type of pain. She denied fevers, chills, cough, diaphoresis, palpitations, dizziness, abdominal pain, heartburn, nausea or vomiting, flu-like symptoms, recent illnesses, or any history of chest pain in the past. Her family history was significant for her brother having an episode of myocardial infarction at age 55.
On detailed inquiry of the patient's history of bladder cancer, the patient reported that she was diagnosed in 2012 after undergoing cystoscopy for an episode of gross hematuria and was found to have a low-grade bladder cancer. She underwent transurethral bladder tumor resection and 1 cycle of intravesical BCG treatment in 2012 and was asymptomatic after that with regular follow-up with urology. On a surveillance cystoscopy performed by the patient's urologist in December 2016, a lesion was seen in the bladder, for which a biopsy was subsequently done which showed papillary hyperplasia and inflammation with no cancer. For this recurrence, the patient was planned for a cystoscopic transurethral bladder tumor resection and instillation of 40 mg of mitomycin C in the bladder, which she underwent three days before her current hospital presentation. The patient was intubated during this procedure which was uneventful, and was subsequently extubated without difficulty.
The patient's oral temperature on presentation was 98.0 F, heart rate of 107/min, respiratory rate of 25/min, and blood pressure of 152/63 mmHg (right arm, supine position). On examination, the patient was in no acute distress and appeared comfortable, although was complaining of having mild chest pain, alleviated by leaning forward. Her laboratory data were as follows: cardiac troponins on the day of presentation, 0.57 ng/ml at 12:30 pm; D-dimer, 257 ng/ml; and white blood cell count, 12.2 K/ml with 67.3% neutrophils. 12-lead electrocardiogram (Figure 1) showed diffuse concave ST elevations with PR depressions in all leads, except in aVR which showed ST depression and PR elevation.
The patient was treated with aspirin 325 mg orally and nebulized albuterol. An echocardiogram was performed which showed normal left ventricular ejection fraction of 61-65%, mid and apical inferior wall motion abnormality, mild to moderate left ventricular diastolic dysfunction, and trivial pericardial effusion. Although the patient's clinical presentation and electrocardiogram findings were consistent with pericarditis, an urgent coronary angiogram was planned due to the possibility of the patient having an acute coronary syndrome, considering her continuing chest pain, elevated cardiac troponin level, echocardiogram findings of mid and apical inferior wall motion abnormality, and the presence of multiple risk factors of ischemic heart disease. The coronary angiogram, performed through right radial artery access, showed a normal left main stem artery, proximal left anterior descending luminal irregularities, a 95% stenotic focal lesion of the mid left anterior descending artery, 40% stenosis of distal left circumflex artery, 30% stenosis of the ostial right coronary artery, 40% stenosis of proximal right coronary artery, 50% stenosis of mid right coronary artery, and 99% stenosis of right posterior descending artery. Left ventricular diastolic pressure was recorded to be 24 mmHg. A single 2.5 x 20 mm synergy monorail drug-eluting stent was placed in the stenosed segment of the mid left anterior descending artery. The patient received 60 mg of prasugrel orally during the procedure, a bolus dose of intravenous tirofiban followed by a maintenance dose intravenous tirofiban drip, and was admitted to the telemetry floor. Dual antiplatelet therapy with aspirin 81 mg daily and prasugrel 10 mg daily was initiated, and the patient was also started on colchicine 0.6 mg every 12 hours for pericarditis. The remainder of the hospitalization was uneventful, and the patient was discharged on the third hospital day, with a plan for a staged percutaneous coronary intervention for the 99% stenotic lesion in the right posterior descending artery in a few weeks.