Elderly Man with Acute Chest Pain

Abstract

A 71-year-old man presented at the emergency department (ED) and reported having acute onset central chest pain the same day while gardening. He described the pain as pressing, throbbing, and radiating posteriorly toward the nape of the neck. The pain was associated with excessive sweating including cold sweats. The patient had a history of hypertension and type 2 diabetes mellitus but denied experiencing any trauma, gastrointestinal symptoms, fever, or constitutional symptoms preceding the episode. On presentation, the patient appeared diaphoretic and in obvious discomfort. There was no discrepancy in blood pressure between his left and right upper limbs. His heart rate was 110 beats/min with a regular rhythm, and he was afebrile. Oxygen saturation was 100% in ambient air. Systematic physical examination results were unremarkable. No murmurs were detected on the cardiovascular examination. Bedside point-of-care cardiac troponin level was grossly elevated at 1220.8 ng/L (99th percentile is 40 ng/L). The patient’s electrocardiogram (ECG) and chest radiograph were taken. The CT aortogram of the patient revealed an impending rupture of an aortic arch aneurysm. Unfortunately, before the CT aortogram, the patient had been given intravenous thrombolytics for a presumed ST-elevation myocardial infarction in a center without a resident cardiologist. The patient was referred to the cardiothoracic surgery team and made an uncomplicated recovery.

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