It would certainly appear that the presentation is most consistent with ischemic heart disease. The acute onset of chest pain with radiation to the left arm is strongly suggestive of this conclusion. She did not have diaphoresis, nausea, or vomiting, all signs and symptoms of ischemic heart disease, but very variable in their presence. Furthermore, as described below, the ischemia may not have been persistent. Although one must consider other causes of chest pain, it is difficult to explain the nature of these complaints with chest wall disease (e.g. costochondritis, or myositis), muscle strain, pericarditis, pleuritis, or parenchymal pulmonary disease (including pulmonary embolism). When one adds the electrocardiographic findings to the clinical complaints, it strengthens the association even further with ischemia. The fact that the cardiac enzymes were within normal limits, simply indicates that the ischemia was transient and did not persist for sufficient time to irreversibly injure the myocardium. It is possible that today, with the use of the more sensitive early marker of myocardial damage, troponin I, that there would have been evidence of myocardial injury, but this marker was not in general use in 1994 when this case occurred. Additionally, the clinical history of multiple episodes of syncope, and the brief period of unconsciousness associated with the acute chest pain events leading to her hospitalization, suggests that ischemia may have been intermittent and causing transient cardiac arrhythmia. Thus, it appears entirely reasonable to assume that this patient had ischemic disease based on her presentation to the hospital; in fact, she was admitted with the working diagnosis of rule out myocardial infarction (ROMI).
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