Notes

The patient is a 73-year-old female with a past medical history significant for hypertension, dyslipidemia, prediabetes, heart failure with reduced ejection fraction (EF ~39%), right ventricular failure, iron deficiency anemia, and osteoarthritis who presented with 1–2 days of chest pain and intermittent shortness of breath. The chest pain was described as right anterior chest pressure, worsened with deep inspiration, and associated with fatigue and exertional dyspnea, with radiation to the right shoulder and scapula. Initial evaluation included laboratory testing with negative troponin, electrocardiogram demonstrating nonspecific ST/T wave abnormalities with left ventricular hypertrophy and occasional PVCs, chest X-ray showing mild cardiomegaly without acute process, and CTA chest negative for pulmonary embolism. Cardiology was consulted for further evaluation of chest pain and possible acute coronary syndrome. Review of prior cardiac workup revealed echocardiogram with EF 39% and moderate diffuse hypokinesis, as well as prior left heart catheterization demonstrating luminal irregularities without obstructive disease. Repeat echocardiogram during admission confirmed reduced EF (~39%) with grade 2 diastolic dysfunction and RVSP approximately 10 mmHg. Inflammatory markers (CRP, ESR, ANA) were ordered given pleuritic component of pain. Overall, no evidence of acute coronary syndrome or decompensated heart failure was identified during this admission.

During hospitalization, the patient was monitored on telemetry and remained hemodynamically stable without recurrence of concerning ischemic symptoms. She was not found to be overtly volume overloaded on exam and did not require diuresis. Guideline-directed medical therapy for heart failure was addressed, with continuation of Entresto and initiation of a low-dose beta-blocker for optimization, with plan for outpatient titration as tolerated. Her chest pain was ultimately felt to be non-cardiac in nature, possibly musculoskeletal or pleuritic, and she was advised to follow up with her primary care physician for further evaluation of right shoulder/scapular discomfort. No further inpatient ischemic workup was recommended by cardiology given recent negative catheterization and stable clinical presentation. Her chronic conditions including hypertension, dyslipidemia, diabetes, and iron deficiency anemia were continued on home management. The patient remained clinically stable throughout admission, tolerated diet, and was deemed appropriate for discharge home with close outpatient follow-up with cardiology and primary care. She was discharged in stable condition with instructions to return for any worsening chest pain, dyspnea, or new symptoms.