But she had a negative stress test!
A 42 y/o female presents to the ED complaining of sudden onset substernal heaviness associated with nausea and a feeling of anxiety and SOB. She has a history of HTN and anxiety, denies drug use, and does smoke cigarettes. She was in your ED 1 month ago for similar symptoms, was observed and ruled out for acute MI, and had a negative treadmill stress test.
As you get ready to contemplate how you are going to handle her disposition, the nurse hands you the first EKG above.
You notice ST elevation in I, aVL, and the anterolateral precordial leads. Cardiology takes her to the cath lab, where just before cath, the second EKG above is obtained. She winds up getting a stent for her near total LAD occlusion, and does well. So how did this happen? She’s a middle aged female, and she just had a recent negative stress test.
Regarding stress tests, multiple studies have shown them to be unreliable in terms of determining ED disposition of patients with chest pain. Sensitivity of stress testing is poor (in the range of 67-85%). A study by Walker et al looked at 164 patients who presented to the ED with chest pain and had negative cardiac stress testing within the last 3 years. Of these patients, 20.7% had CAD, 8 of whom had CAD within a month of their negative stress test (1). This and other studies have shown that a recent negative stress test, even within a month, cannot be reliably used in disposition of ED patients with chest pain.
Regarding women, studies show that we miss more CAD in women. Women can have CAD too, and you cannot treat them any differently. Remember that by coming to the ED, patients have already self selected themselves as inherently higher risk than non-ED patients, and a good history and physical is key to their evaluation.
1. Walker J, Galuska M, and Vega D. Coronary Disease in Emergency Department Chest Pain Patients with Recent Negative Stress Testing. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2967694/