What is the appropriate management for a 42-year-old female presenting with near syncope (near fainting), dizziness, tachycardia (rapid heart rate), chest pain, and shortness of breath?

From the Guidelines

The appropriate management for a 42-year-old female presenting with near syncope, dizziness, tachycardia, chest pain, and shortness of breath requires immediate evaluation in an emergency department setting. Initial management should include placing the patient on continuous cardiac monitoring, obtaining vital signs, establishing IV access, and administering supplemental oxygen if oxygen saturation is low 1. A 12-lead ECG should be performed promptly to assess for arrhythmias, ischemic changes, or other cardiac abnormalities, as recommended by the European Society of Cardiology for patients presenting with acute chest pain 1.

Key Diagnostic Tests

• Laboratory tests including complete blood count, electrolytes, cardiac enzymes (troponin), D-dimer, and arterial blood gases are essential for evaluating the patient's condition 1.
• Additional diagnostic tests should include chest X-ray and possibly echocardiogram to evaluate cardiac structure and function, as well as CT angiography (CTA) with contrast to rule out pulmonary embolism if suspected 1.
• Consideration should be given to the patient's symptoms, such as unexplained shortness of breath, chest pain, tachycardia, apprehension, or tachypnea, which may indicate pulmonary embolism 1.

Symptomatic Management

• While awaiting results, symptomatic management may include positioning the patient supine with legs elevated if hypotensive, administering IV fluids for volume support if indicated, and considering medications such as beta-blockers (e.g., metoprolol 5mg IV slowly) if tachycardia persists without hypotension.
• The patient should not be discharged until a clear diagnosis is established or serious conditions are ruled out, as these symptoms represent potentially life-threatening conditions requiring prompt intervention 1.

Potential Diagnoses

• This constellation of symptoms raises concern for several serious conditions including acute coronary syndrome, pulmonary embolism, cardiac arrhythmia, or aortic dissection, all of which require rapid diagnosis and treatment 1.

From the FDA Drug Label

Nitroglycerin is a type of medicine known as an organic nitrate and is a vasodilating agent. It is used to treat a type of chest pain called angina. Nitroglycerin sublingual tablets can relieve this pain. One tablet should be dissolved under the tongue or in the oral cavity at the first sign of chest pain.

The appropriate management for a 42-year-old female presenting with near syncope, dizziness, tachycardia, chest pain, and shortness of breath may include nitroglycerin sublingual tablets if the chest pain is determined to be angina. However, it is crucial to first assess the patient's condition and determine the cause of the symptoms.

• The patient should be seated when taking nitroglycerin sublingual tablets to avoid falling due to potential dizziness or lightheadedness.
• The dose may be repeated approximately every 5 minutes, until the chest pain is relieved.
• If the pain persists after a total of 3 tablets in a 15-minute period, or is different than the patient typically experiences, the patient should call their doctor or seek emergency help 2.

From the Research

Presentation and Symptoms

• The patient presents with near syncope, dizziness, tachycardia, chest pain, and shortness of breath, which are symptoms that may indicate acute myocardial infarction (AMI) or other cardiac conditions 3, 4.
• These symptoms can also be associated with other conditions such as pulmonary embolism, pericarditis, or myocarditis, which can cause myocardial injury and elevated troponin levels 5, 6, 7.

Diagnostic Approach

• The use of high-sensitivity cardiac troponin assays is recommended for the diagnosis of AMI, with a threshold of the 99th percentile of a healthy reference population 3, 4.
• A single admission troponin measurement with a lower cutoff combined with a low-risk electrocardiogram (ECG) can be used to rule out AMI, with a negative predictive value of 99.3% 5.
• Serial measurements of high-sensitivity troponin can be used to rule out AMI, with an assay-specific cutoff at the 99th percentile 3, 4.

Electrocardiogram and Troponin Correlation

• Signs of myocardial ischemia on ECG, such as T-wave inversion and ST-depression, correlate with elevated plasma cardiac troponin and right ventricular systolic dysfunction in acute pulmonary embolism 6.
• The correlation between ECG changes and troponin levels can help differentiate between causes of myocardial injury and infarction, but troponin concentrations at presentation are insufficient to distinguish type 1 myocardial infarction from other causes of myocardial injury or infarction in practice 4.

Differential Diagnosis

• The patient's symptoms and elevated troponin levels can be caused by various conditions, including AMI, pulmonary embolism, pericarditis, myocarditis, and other cardiac conditions 3, 4, 5, 6, 7.
• A comprehensive diagnostic approach, including ECG, troponin measurements, and clinical evaluation, is necessary to determine the underlying cause of the patient's symptoms and to guide management decisions 3, 4, 5, 6, 7.