Case Report

A 66-year-old Caucasian female with no past medical history presented with four hours of dyspnea. The patient stated that two days prior to presentation she developed severe, crushing substernal chest pain that awoke her from sleep. The pain was non-radiating, lasted 30 minutes, and was associated with diaphoresis, shortness of breath, nausea, and lightheadedness. Her medical history was unremarkable except for a 50-pack-year smoking history.

On presentation, the patient was tachycardic to 110 beats per minute, and tachypnic at 22 breaths per minute. Cardiac auscultation revealed a 4/6 holosystolic murmur radiating to the axilla that was audible throughout the precordium. Pulmonary exam revealed rales at the bases bilaterally. JVP was elevated to the angle of the mandible. Though she was initially able to breathe comfortably and speak in full sentences, over the next hour she developed increased work of breathing and respiratory distress.