Cardiovascular Board Review

A 37-year-old man with chest pain, ECG changes, and elevated cardiac enzymes

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A 37-year-old African American man presents to the emergency department with chest pain and dyspnea, which began suddenly 30 minutes ago. The pain is severe, pressure-like, nonradiating, and pleuritic.

His heart rate is 88 beats per minute, blood pressure 135/72 mm Hg, respiratory rate 12 per minute, and oral temperature 38.5°C (101.3°F). His oxygen saturation by pulse oximetry is 99% while breathing room air. He is given sublingual nitroglycerin, but this does not alleviate his pain.

Figure 1. The patient’s electrocardiogram on admission. See text for interpretation.

On physical examination, he is a physically fit man in obvious distress. His jugular veins are not distended, and no lymph nodes are palpable in his neck. The heart sounds are muffled without murmurs, but a faint pericardial friction rub is heard that persists even when he holds his breath. His lungs are clear to auscultation, his abdomen is normal, and his lower extremities are warm, with normal pulses and no edema. Of note, neither a Kussmaul sign nor a paradoxical pulse is present. An electrocardiogram is ordered (Figure 1).

While blood samples are being drawn, we learn more about his history. He has hypertension, for which he takes amlodipine (Norvasc), and gastroesophageal reflux under control with esomeprazole (Nexium). He says he does not have hyperlipidemia, diabetes, or coronary artery disease and his surgical history is unremarkable. He says he does not smoke, rarely drinks, and does not use any drugs. No one in his family has had premature coronary artery disease.

He says he has had similar symptoms in the past few months, which resulted in two emergency room visits. Electrocardiograms at those times were unremarkable, and a stress test was negative for ischemia.

A computed tomographic (CT) scan of the chest was also obtained during one of those visits. The scan was negative for a pulmonary embolus but incidentally showed liver hemangiomas.

He goes on to add that his chest pain has recently increased in frequency, and it has occurred daily for the past 5 days. The pain is not related to exertion, occurs throughout the day, and is associated with significant shortness of breath. It worsens when he is taking a deep breath and improves when he leans forward. Although he is febrile, he says he has had no fevers or chills in the past. He gives no history of weight loss, cough, orthopnea, or paroxysmal nocturnal dyspnea, but has been experiencing malaise, weakness, and myalgia for the past month. His review of systems is otherwise negative.

The patient’s initial laboratory results are shown in Table 1.

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