Chest pain or suspected myocardial infarction accounts for up to 20% of emergency department visits. Evaluation for coronary artery disease may delay the diagnosis of non-cardiac chest pain.
A 69 year old woman presented to the emergency department with intermittent left sided chest pain for 1 week. It felt like a burning or tightness, without radiation but with associated lightheadedness. She also had nausea with 1 episode of emesis. Medical history was significant for hypertension, dyslipidemia, peripheral vascular disease with iliac angioplasty in 1998, hypothyroidism, polymyositis in remission, bilateral shoulder avascular necrosis associated with steroid use, right shoulder arthroplasty, peptic ulcer disease and ischemic colitis. She has a 20-30 pack/year smoking history. Daily medications include amlodipine 5 mg, atorvastatin 10 mg, levothyroxine 125 mcg, aspirin 325 mg. Review of systems elicited mild dyspnea on exertion but no lower extremity edema or orthopnea. Cardiovascular and pulmonary examination was normal. The pain resolved with sublingual nitroglycerin and intravenous heparin. Diagnostic coronary angiogram performed the next morning revelaed no occlusive coronary artery disease, but left ventriculogram revealed a spade-shaped left ventricular cavity. This was confirmed with transthoracic echocardiogram, left ventricular ejection fraction was 80%. There was no significant outflow obstruction at rest. With valsalva maneuver, an intracardiac gradient of 45 millimeters of mercury was evident. BB was discharged home with a presumptive diagnosis of subendocardial ischemia. Ten days later she returned to the emergency department with chest pain which improved with fasting and a low-fat diet. Abdominal computed tomography revealed free air anterior to the liver capsule, so emergent exploratory laparotomy was performed. Pus and fluid was present in the abdominal cavity, and a 1.5 x 1.5 cm perforated duodenal ulcer was repaired. She recovered well and was discharged home in stable condition.DISCUSSION: Apical hypertrophic cardiomyopathy, also known as Yamaguchi disease, was first described in the late 1970’s in Japan, where it may account for up to 25% of hypertrophic cardiomyopathy. Elsewhere in the world, it is less that 1%. This disease is usually diagnosed in the 5th decade of life, with males greatly outnumbering female cases. Electrocardiogram may reveal left ventricular hypertrophy with deeply inverted T waves, known as “giant negative T waves” in leads V4-V6. There is a good prognosis, with up to 95% 15-year survival.CONCLUSIONS: Morphologic heart disease may be identified during cardiac evaluation for other reasons. In this case it led to a premature cessation of diagnostic testing for the etiology of chest pain. Emergency surgery could have been avoided if a more complete evaluation was undertaken at the initial presentation. Diagnostic testing should be expanded to include common non-cardiac etiologies of chest pain.
D.M. Safley, None.