A Curious Case of Chest Pain

A CLINICAL PROBLEM-SOLVING article by Joshua Liao, from Brigham and Women's Hospital, Boston.
A 67-year-old man presented to the emergency department with chest pain. 10 days before presentation, nausea, nonbloody emesis, bloating, and epigastric pain developed. A presumptive diagnosis of gastroesophageal reflux was made. Over the course of several hours on the day of presentation, heaviness of the chest developed on exertion and progressed to pain at rest accompanied by diaphoresis and dyspnea. The pain was substernal and nonradiating, and it did not change with a change in position or with food intake.
On examination, the patient appeared uncomfortable, pale, and diaphoretic, and he was using his accessory muscles to breathe. The patient appears to have acute heart failure, with evidence of elevated right-sided and left-sided filling pressures and impaired perfusion. Potential causes of acute biventricular failure include myocardial ischemia, a mechanical complication caused by a recent myocardial infarction, acute regurgitant valvular lesions, an acute aortic syndrome, or acute myocarditis.
The patient's rapidly downhill course despite appropriate treatment of heart failure differentiated his condition from other disorders. This NEJM.org to use an interactive medical case associated with this article.