Chest Pain: A Repeat Visit

Hx: A 39 yo female complains of chest pain. It began today, is felt as a pressure in the mid chest with a sensation of heart racing, and is associated with shortness of breath. She also has significant associated anxiety. She notes a similar episode one week ago when she was seen in the emergency department and had negative cardiac studies (labs, egg, etc). At that time,  symptoms started after smoking marijuana and were improved with ativan. She denies marijuana use today. She denies any medical history or family history. No prescriptions. No recent illnesses. She exercises regularly and denies any recent injuries.

PMHx: Uterine Fibroids (intends on having surgery at some point but has no doctor right now)

SocHx: Occasional tobacco, marijuana, and alcohol.

Meds: none

Exam:

  • General: tearful, anxious
  • HEENT: normal
  • Resp: tachypneic, hyperventilating, clear bilaterally
  • Cardiovascular: heart regular at 75, pulses normal, patient feels heart racing during exam.
  • Abdomen: soft, non-tender, normal bowel sounds.
  • Extremities: warm, no deformities, no swelling or tenderness.
  • Neuro: canal nerves normal, no defecits
  • Psych: anxious. tearful, recent death in family causing increased stress.
DDx:
  • PE
  • AMI/UA/ACS
  • Anxiety/Panic Attack
  • Bronchospasm
  • Substance abuse
  • Alcohol withdrawal
  • Arrhythmia
  • Coronary vasospasm (prinzmetal angina)
  • Hyperthyroidism
  • Symptomatic Cholelithiasis
Diagnostics: 
  • ECG- normal sinus rhythm, no ST elevations, normal QRS
  • Chest xray – normal
  • Prior Labs: laboratory results form one week ago reviewed and show troponin negative x 2, CBC, CMP, urinalysis, and UCG negative.
  • CBC, CMP, and Troponin this visit are negative.
  • D-Dimer elevated
  • CT pulmonary angiogram reveals multiple bilateral lower lobe pulmonary emboli, no DVT, and a large fibroid uterus. (see images)
PE01

Red arrows show intravascular clot (filling defect in the vessel)

PE02

Red arrows show intravascular clot (filling defect in the vessel)

PE03

Red arrows show intravascular clot (filling defect in the vessel)

PE04

Red arrows show intravascular clot (filling defect in the vessel)

PE05

Red arrows show intravascular clot (filling defect in the vessel)

PE06

Red arrows outline the large uterine fibroid

Hospital Course:
  • Started anticoagulation without complication.
  • Ultrasound of abdomen showed unremarkable aorta and IVC.
  • Ultrasound of bilateral lower extremities was normal
  • The patient was ultimately discharged with a diagnosis of “unprovoked” pulmonary embolism to continue with a delayed hysterectomy.
Discussion:

The diagnosis of pulmonary embolism is a challenging one to make. This is due, in no small part, to the similarity of the symptoms to other conditions. It is also due to the fact that suspicion of pulmonary embolism has traditionally been the key factor in the search for the condition. With the increased use of CT imaging, the diagnosis has increased. However, with the growing concerns over radiation exposure from CT, the d-dimer assay was added to the recommended approach. It detects the components of fibrinolyisis (clot breakdown). However, the test is non-specific and therefore is coupled with a pre-test probability score derived from history. This brings us back to suspicion as the driver of the search for the diagnosis since the pre-test probability score is based on historical elements like hx of prior DVT/PE, lower extremity swelling or pain, recent trauma or surgery, history of malignancy, etc. (Wells Criteria Calculator, PERC Rule Calculator). Though the addition of d-dimer testing and CT angiography has led to an increase in the incidence of pulmonary embolism since the 1990’s, the reliance on pre-test suspicion in a somewhat deceptive condition leaves room for improvement.

This cases raises an important question: should the presence of large uterine fibroids be considered an independent risk factor for pulmonary embolism? There are a number of case reports and at least one observational study citing a relationship between large uterine fibroids and thromboembolism. A 2011 observational study (https://www.ncbi.nlm.nih.gov/pubmed/21576892) found an almost 4 fold increase in the rate of DVT in women with uterine weight over 1000 grams (11.5%) vs those with a smaller uterine size (3.0%). Although none of the women in the small 361 patient study developed PE, the study does show an increased risk. Although there are no national guidelines or recommendations regarding risk of venous thromboembolism in patients with uterine fibroids, it seems prudent to consider the presence of a large uterine fibroid a risk factor and to ask a few more questions regarding the presence of pelvic pain or leg swelling.

A list of current published studies and a reviews on this topic:

Disclaimer

De-identificaiton is undertaken utilizing the Safe Harbor method described by the US Department of Health and Human Services. All remaining patient information required for teaching purposes has been altered to maintain this standard.

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