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‘Hearing hooves, finding zebras’: the differential diagnosis of cardiac arrest precipitated by chest pain in the postpartum woman
  1. Gareth Squire1,2,
  2. Mohammed Eltayeb3 and
  3. Kai Hogrefe4
  1. 1 Molecular Cell Biology, University of Leicester, Leicester, UK
  2. 2 Research Division, University Hospitals of Leicester, Leicester, UK
  3. 3 Cardiology, University Hospitals of Leicester NHS Trust, Leicester, UK
  4. 4 Cardiology, Kettering General Hospital NHS Foundation Trust, Kettering, UK
  1. Correspondence to Dr Gareth Squire, gs303{at}


We describe the case of a 3-week postpartum 27-year-old woman who presented with chest pain to the emergency department shortly before developing cardiac arrest with refractory ventricular fibrillation. She was initially misdiagnosed and treated for presumed pulmonary embolism (PE) with thrombolysis. A total of 14 direct current cardioversion shocks were given and return of spontaneous circulation (ROSC) was achieved post thrombolysis. Subsequent CT pulmonary angiography excluded PE. A post-ROSC ECG demonstrated anterolateral ST elevation and she was transferred to the local cardiac unit for angiography. This revealed extensive dissection of the left anterior descending artery (LAD) with proximal occlusion. The diagnosis therefore was pregnancy-associated spontaneous artery dissection, a type of acute coronary syndrome. She received percutaneous intervention to her LAD with five drug-eluting stents. The patient survived and was discharged 5 days later. Her ventricular function is now grossly impaired, and had the correct diagnosis been arrived at sooner, this loss of function would have been less severe.

  • interventional cardiology
  • venous thromboembolism
  • resuscitation
  • pregnancy

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  • Contributors GS, ME and KH looked after the patient. GS wrote the first draft. KH acted as senior author. All authors contributed to the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.