Clinical Reasoning Conference – July 2021

For our first Clinical Reasoning Conference of the academic year, our expert diagnostician was the incomparable Dr. Lori Daniels, cardiologist extraordinaire and a former chief resident of our program. Dr. Daniels walked us through the mystery case of a relatively healthy young woman who presented with acute-onset, sharp midsternal chest pain and was found to have dynamic EKG changes, elevated cardiac biomarkers, and apical hypokinesis on echocardiogram. A computed tomography of the coronary arteries showed abrupt tapering of the mid- to distal left anterior descending artery, which was consistent with spontaneous coronary artery dissection (SCAD). With treatment and cardiac rehabilitation, the patient had a good cardiac recovery. She was ultimately diagnosed with an arteriopathy.

We took this opportunity to discuss the uncommon but important diagnosis of SCAD, caused by hematoma formation within the tunica media, which then leads to intimal separation from the underlying vessel. Triggers include stress, Valsalva, intense exercise, hormonal changes, and medications. Most cases occur in young women with few traditional cardiac risk factors. SCAD can be associated with pregnancy and can occur in the postpartum setting. SCAD can present similarly to other causes of acute coronary syndrome (ACS), with typical chest pain, elevated cardiac biomarkers, EKG changes (including ST segment elevations), and wall motion abnormalities. Most cases are diagnosed through cardiac catheterization. Thrombolytics are generally avoided as they may cause extension of the dissection or hematoma. The role of antiplatelet agents and anticoagulants in SCAD is unclear, but these agents are often given. Neurohormonal block with β-blockers and ACE inhibitors (or ARBs) is also typically initiated. Percutaneous coronary intervention and coronary artery bypass graft surgery may be appropriate in select patients.

We were fortunate to have been joined by the patient, who shared her unique perspective on the experience. The classic teaching that women with ACS tend to present atypically is flawed. Studies suggest that women who have ACS report typical chest pain at similar rates as men who have ACS. Although women have higher rates of insurance and primary care than men, women who develop ACS report more difficulty receiving care than their male counterparts. In addition, despite having a higher cardiac risk burden and risk of severe myocardial infarction, women who have ACS are less likely to be appropriately diagnosed on presentation and less likely to be reperfused in a timely manner. Indeed, health inequities related to sex and other social determinants of health remain pervasive today.

Key Learning Points:

  1. SCAD is an important cause of acute coronary syndrome, particularly in young women who have few traditional cardiovascular risk factors.
  2. Not all chest pain is from atherosclerotic plaque rupture. Consider other diagnoses such as aortic dissection, pulmonary embolism, pneumothorax, and SCAD.
  3. In SCAD, most medications used to treat other causes of acute coronary syndrome can be delayed and administered after an angiogram without significant issues.
  4. Discrepancies related to sex and other social determinants of health in the management of individuals who present with chest pain remain commonplace.

Thank you to Dr. Daniels and our other expert discussants for participating in our conference today!

JMC PM Report 12/11: The Diagnostic Schema!

This afternoon at Jacobs, we continued to explore our longitudinal clinical reasoning curriculum by doing a deep dive into the concept of the diagnostic schema! As a reminder, the diagnostic schema is a conceptual approach to specific symptoms or diseases that is meant to organize the way we approach a differential diagnosis. Importantly, the schema does not need to be entirely comprehensive, but is built such that you can rationally approach a disease category and use it to guide work-up and management. As an example, the team discussed their different approaches to post-prandial pain!

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A common cause of post-prandial abdominal pain!

Owen Conference AM Report–Tue, 10/15/19

As part of our Owen (HIV) AM report series, CMR Janet Ma walked us through a case of a young woman with AIDS presenting with a unilateral leg rash.  Our AMAZING senior residents (R2s Mary Brooks, Sophie Cannon, Ashley Scanlon and Cynthia Hsu) led the group in sharing their diagnostic schema for rash in an immunocompromised patient.  The ultimate diagnosis was multidermatomal zoster! Dr. Anand Jagannath (VA Hospitalist) and Dr. Lalo Cachay (Owen/ID attending) shared their approach and expertise.