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Presenter: A 35-year-old female, with the following chief complaints:

Shortness of breath (SOB) since 7 days and chest pain since 4 days.

Patient was apparently asymptomatic 7 days back; thereafter, she developed SOB, which was sudden onset, and New York Heart Association functional class (NYHA FC) III, which progressed to FC IV over the next 2 days and was also associated with orthopnea. Patient had no history of paroxysmal nocturnal dyspnea (PND) episodes.

Chest pain—one episode 4 days back, sudden onset, retrosternal, squeezing type, associated with sweating, continued for 30 minutes, and was relieved with medication.

Patient did not have any history of palpitations, syncope, bilateral swelling of legs, reduced urine output, facial puffiness, fever, cough, abdominal pain or distension, vomiting, diarrhea, back pain, skin rash, weight loss, easy fatigability, joint pain, ulcerations in the body, and history suggestive of rheumatic disease in past.

Obstetric history: She had a past history of four spontaneous abortions as well as a history of surgery for ovarian cyst (8 years back). She conceived with in vitro fertilization (IVF) but spontaneously aborted.

Patient had no similar complaints in the past. She is a homemaker. Patient takes mixed diet. She is not a known smoker, alcoholic, or tobacco chewer. Patient is not using any other medication. Family history was not suggestive of any cardiac disease or other medical illnesses in her family.

Discussant: To summarize the clinical details, a 35-year-old female presented with sudden onset of dyspnea since 7 days, progressed from class III to IV in 2 days, one episode of chest pain 4 days back, and past history of abortions. Based on clinical presentation, the differential diagnoses included the following:

Antiphospholipid antibodies (APLA) syndrome: These patients presented with vascular thrombotic events in the form of deep vein thrombosis (DVT), acute pulmonary thromboembolism, acute coronary syndrome (ACS) due to thrombotic occlusion of coronaries, and recurrent abortions; hence, the possibility of APLA syndrome can be considered as first possible diagnosis.[1]

Systemic lupus erythematosus (SLE): SLE patients presented with fever, joint pains, myalgias, skin rashes, cardiac involvement in the form of pericarditis and myocarditis. So, these patients can present as SOB and chest pain; however, no prodromal symptoms were seen in the patient.

ACS: Patients diagnosed with ACS manifest with chest pain and dyspnea if the patient developed left ventricular (LV) dysfunction, and they were also predisposed to develop arrhythmias. In our patient, coronary artery disease (CAD) can be considered.[2]

Dilated cardiomyopathy (DCMP): Patients diagnosed with DCMP usually manifest with SOB, which is usually insidious in onset and gradually progressive, and atypical chest pain. Patients diagnosed with DCMP will usually have long duration of symptoms; however present patient had breathlessness of only 7 days duration.

Viral myocarditis: Patients diagnosed with viral myocarditis usually have SOB, which is sudden in onset and includes chest pain. Hence, in this patient, there is high possibility of viral myocarditis. However, this patient did not elicit any inciting event.

Hypertrophic cardiomyopathy (HCM): Patients diagnosed with HCM usually develop symptoms by the 3rd and 4th decade.[3] HCM patients present with chest pain, syncope, palpitations, and SOB.[4] HCM patients present as dilated cardiomyopathy in the late burnt-out stages. About 60% patients usually have a positive family history of cardiomyopathy.[5] In the present case, family history was absent, and patient had sudden onset of symptoms.

Infiltrative cardiomyopathy: Patients diagnosed with infiltrative cardiomyopathy usually present with SOB and chest pain after 6th decade. Infiltrative cardiomyopathy usually manifest as a component of multisystem disorder.[6] In our present patient, there were no clinical manifestations related to other systems.

Calcific degeneration of bicuspid aortic valve: Patients with significant aortic stenosis (AS) due to calcific degeneration of bicuspid aortic valve present with angina, syncope, and SOB.[7] These patients have a slightly longer history of symptoms. Our patient had sudden onset of SOB and chest pain and no history of syncope and palpitations.

Presenter: On general physical examination, patient was conscious, coherent, and oriented. Her body mass index (BMI) was 23 kg/m2 and temperature 98.4 °F. Pulse rate was 120 beats/min, and regular blood pressure was 190/100 mm Hg in right arm supine position and 200/100 in right lower limb. Respiratory rate was 34 cycles per minute and oxygen saturation was 99% on room air. Pallor was present, and there were no signs of icterus, cyanosis, clubbing, edema feet or lymphadenopathy. On cardiovascular (CVS) examination, jugular venous pressure (JVP) had normal mean column height and normal wave pattern. Apex beat was localized in left 5th intercostal space half inch medial to midclavicular line, LV type. First heart sound was normal in intensity. Second heart sound was normal in intensity and split. No added sounds were present. On auscultation of lungs, fine crackles were found. There was no evidence of organomegaly. No epigastric pulsations were noted on per abdomen examination. Central nervous system (CNS) examination was normal.

Discussant: Summary of the examination findings are blood pressure of 190/100 mm Hg in right arm supine position, pallor, and respiratory rate was 34 cycles per minute.

Keeping in mind history as well as examination findings, the probable differential diagnosis is:

Hypertensive heart failure: Presented with hypertension and cardiac involvement in the form of ischemic symptoms like chest pain and failure symptoms like SOB. Hypertensive heart disease can manifest as either systolic heart failure or diastolic failure or both. Hypertensive heart disease patients are more prone to develop acute events like decompensated heart failure, acute coronary events, or sudden cardiac death.[8] Hypertension (HTN) disrupts the endothelial system, which increases the risk of CAD and peripheral arterial disease (PAD) and thus represents a significant risk factor for the development of atherosclerotic disease.

APLA syndrome: is an autoimmune disorder present as recurrent abortions and thromboembolic events like DVT, acute pulmonary thromboembolism and ACS. This patient has history of abortions, and acute coronary symptoms can be considered as initial differential diagnosis.

Autoimmune overlap syndromes: About 25 to 45 percent cases of APLA are associated with SLE. This can manifest as hypertension due to lupus nephritis, recurrent abortions and thrombotic events such as ACS, pallor due to hemolytic anemia, but other manifestations like skin involvement are absent in this case.

Early atherosclerosis: Early atherosclerosis can manifest as hypertension and acute coronary events. High blood pressure on its own increases atherosclerosis risk by 60 percent. Early atherosclerosis of renal and coronary vessels present as HTN and HTN-induced chronic kidney disease which manifests as anemia, renal failure and acute coronary events. Early atherosclerosis can be considered as initial diagnosis, but the female sex and age of presentation are against the atherosclerosis.[9] [10]

Infiltrative cardiomyopathy: Infiltrative cardiomyopathy patients usually present with diastolic heart failure, concentric hypertrophy in initial stages, and in advanced stage, present as DCMP[11] Occurrence of complete heart block and supraventricular tachyarrhythmia is high due to infiltration of conduction system and atrial dilatation. The typical features are absent in the present case.

Hypertensive HCM: Hypertension of mild-to-moderate degree sometimes occurs in patients with HCM, but it is predominant among the elderly. Early age of presentation in our case and anemia usually rules out this condition.[12]

Final Diagnosis

Thrombosed AAA in a young female due to early atherosclerosis.

Publication History

Publication Date:
31 October 2021 (online)

© 2021. Women in Cardiology and Related Sciences. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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