โ Scribed by Mintu P. Turakhia; Blair P. Grubb; Gabriel Gregoratos
No coin nor oath required. For personal study only.
The Irritable Heart A 30-year-old woman was referred for evaluation of chest pain, palpitations, and exercise intolerance. She had been previously healthy, active, and physically fit. Five months prior to our evaluation, she had an elective C5-C6 cervical spine discectomy with interbody allograft fusion for a chronic neck injury that occurred 11 years ago during gymnastics. Two weeks after spine surgery, the patient developed numbness and tingling of her left thumb and palm that occurred with exertion or exposure to cold and subsided with rest. These episodes increased in frequency and intensity and after 1 week became associated with sharp, occasionally stabbing chest pain that radiated to the left arm. On one occasion, the patient had an episode of exertional chest pain with prolonged left arm cyanosis. Emergent left upper extremity angiography revealed normal great vessel anatomy with spasm of the radial artery and collateral ulnar flow. The patient was diagnosed with Raynaud's phenomenon and was started on nifedipine. A subsequent rheumatologic evaluation was unrevealing, and the patient was empirically switched to amlodipine with no improvement in symptoms.
This otherwise very healthy 30-year-old developed a multitude of symptoms. The patient's chest pain is atypical and in a young woman is unlikely to signify atherosclerotic coronary disease, but it should not be entirely disregarded. Vasospasm triggered by exposure to cold does raise suspicion for Raynaud's phenomenon, which is not uncommon in this demographic. However, this presentation is quite unusual because the vasospasm was limited to one vascular distribution of one extremity. Associated coronary vasospasm could explain the other symptoms, although coronary spasm is generally not associated with Raynaud's phenomenon. Vasculitis may also affect the pulmonary vasculature, leading to pulmonary hypertension and exercise intolerance. The temporal association with her spine surgery is intriguing but of unclear significance.
The patient continued to have frequent exertional episodes of sharp precordial chest pain radiating to her left arm that were accompanied by dyspnea and left upper extremity symptoms despite amlodipine therapy. These now occurred with limited activity when she walked 1 to 2 blocks uphill. Over the The authors thank Gurpreet Dhaliwal, MD, for his review of this article.
๐ SIMILAR VOLUMES
Retail "I had nightmares, flashbacks. I dissociated... Changes in self-perception and hallucinations-those are some of my other symptoms. You are poison, I chanted silently to myself. And your poison is contagious." So begins Mac McClelland's powerful, unforgettable memoir, *Irritable Hearts*. Wh