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The Sweatshirt Sign: Coronary Artery Disease

Sweatshirt with “abnormal wear” pattern over left chest caused by rubbing. (C) Cardiac catheterization showing coronary artery disease involving the left main, left anterior descending, diagonal, obtuse marginal, and right coronary arteries.

Sweatshirt with “abnormal wear” pattern over left chest caused by rubbing. (C) Cardiac catheterization showing coronary artery disease involving the left main, left anterior descending, diagonal, obtuse marginal, and right coronary arteries.

 

In one memorable case, the patient’s attire told physicians more about his health than the initial interview and physical examination. A 65-year-old veteran with a history of dyslipidemia, hypothyroidism, and post-traumatic stress disorder presented for a routine primary care visit and had no symptoms. He specifically denied having any chest pain.

Assessment

When asked about the unusual pattern of wear on his sweatshirt (Figure A and B), the patient admitted to having daily exertional chest pressure over the previous 7 months. This was relieved by rest and by pushing down on the area of discomfort and rubbing it. An electrocardiogram was unremarkable.

Diagnosis

A nuclear stress test revealed a large area of reversible ischemia. On the basis of the severity of his symptoms, the patient opted to undergo invasive testing. He was noted to have significant multivessel coronary artery disease on cardiac catheterization (Figure C) (70% blockage, left main coronary artery; 99% blockage, left anterior descending artery; 80% blockage, diagonal branch of the left anterior descending artery, 99% blockage, obtuse marginal branch of the circumflex artery; and 90% blockage, right coronary artery).

Management

The patient underwent successful coronary artery bypass grafting. Atrial fibrillation developed 3 months later and has been managed with amiodarone. Clinicians should remember to ask patients whether they are experiencing “chest discomfort” rather than “chest pain.” It is also essential to be aware of the sweatshirt sign, which we call “the abnormal wear sign.”

 

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-Daniel G. Federman, MD, Steven E. Pfau, MD

This article originally appeared in the December 2016 issue of The American Journal of Medicine.

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