Keith R. Oken, MD

After a family argument, an 83-year-old woman experienced chest pain, a "racing heart," and a choking sensation and was brought to the emergency department. The chest pain lasted 10 to 15 minutes; was sharp, substernal, and nonradiating; and was associated with dyspnea and a bout of emesis. A sublingual nitroglycerin tablet partially alleviated the pain, but the patient felt syncopal. Her symptoms persisted despite the administration of supplemental oxygen and a second sublingual nitroglycerin tablet. The patient had a history of gastroesophageal reflux disease, allergic rhinitis, and osteoarthritis. Her oral medications included esomeprazole (40 mg/d), aspirin (81 mg/d), and fluticasone nasal spray. She had discontinued valdecoxib 3 weeks earlier.