Case Presentation: A 39 year-old woman presented with 4 months of progressive dyspnea on exertion and chest tightness. Her symptoms first began near the end of her usual 2 mile walk, resolving with rest after several minutes. The dyspnea and chest pain continued to occur with progressively less exercise until she was experiencing symptoms during her routine daily activities. A trial of bronchodilator therapy did not alleviate her symptoms. She otherwise felt well at rest and denied fevers, chills, cough, radiating chest pain, lower extremity pain, orthopnea, or swelling. Her past medical and social history were remarkable only for Reynaud’s syndrome. She was a non-smoker. Her family history was notable for coronary artery disease in her father at age 60. Her vital signs were normal at rest. Heart rate was regular with no murmurs or gallops. Jugular venous pulse was flat. Her lungs were clear, and her extremities demonstrated strong pulses without pitting edema. Her complete blood count, metabolic panel, liver tests, and troponin were normal. Chest radiograph was unremarkable. Resting electrocardiogram demonstrated normal sinus rhythm with normal axis and intervals, and an isolated T wave inversion in lead III.
She underwent cardiac stress testing which provoked chest pain at 8 minutes of moderate exercise, associated with reversible ST elevations in the inferior leads and a brief period of 2:1 conduction block. Echocardiogram demonstrated inferior wall hypokinesis. Cardiac catheterization showed no coronary artery disease, but instead showed a “difficult to engage right coronary artery.” Cardiac MRI revealed an anomalous right coronary artery with origin from the left coronary cusp, passing anteriorly between the aorta and pulmonary artery with associated stenosis. Given these findings, cardiac surgery performed an anomalous right coronary artery re-implantation with resolution of her stenosis. She was discharged on aspirin and metoprolol, and experienced no further symptoms.
Discussion: This case describes angina, a common presenting symptom for hospitalists, caused by an anomalous coronary artery, a rare condition. The patient lacked the typical profile and risk factors for the presence of coronary artery disease, demonstrating the potential failure that hospitalists face applying medical heuristics to medical diagnosis. Medical heuristics are mental “shortcuts” used by hospitalists to assist in diagnosing and treating patients in the acute hospital setting. While useful, heuristics can lead to missed or delayed diagnoses, or incorrect evaluation of symptoms. This patient had the classic symptomatology of angina. However, the cause of her angina was unpredictable, resulting in a mental shortcut that initially overlooked the true diagnosis. This highlights common pitfalls in medical heuristics: representation error and premature closure. Fortunately, advanced diagnostic testing revealed the true cause of her symptoms, preventing patient harm.
Conclusions: Hospitalists regularly engage in medical heuristics to assist in making quick and accurate medical diagnoses. However, this strategy may overlook the diagnosis if the presentation is unusual, the underlying cause is rare, or if the case does not fit into predetermined medical “shortcuts.” Angina in a young healthy female caused by an anomalous coronary artery meets this categorization. Hospitalists must therefore be diligent in using these analytic tools to ensure patients receive accurate diagnoses and prompt medical treatment.
To cite this abstract:Ronan M, Hill M. Don’t Always Trust Your Heart. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 670. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/dont-always-trust-your-heart/. Accessed July 16, 2019.