Cases in Electrocardiography
A 69-year-old man with a history of hypertension, possible congestive heart failure, hyperlipidemia, and peptic ulcer disease presented to the ED with two days of intermittent low substernal chest discomfort at rest and with exertion. He had mild associated shortness of breath, vague nausea, yet no diaphoresis, dizziness, or dyspepsia.
The discomfort lasts anywhere from five to 20 minutes. Past medical history was otherwise noncontributory. Medications included lisinopril, digoxin, atorvastatin, and aspirin. Physical examination was normal at the time of ED evaluation, during which time the patient was free of chest discomfort. An ECG (Figure 1) was obtained, and no prior tracings existed for comparison. Chest x-ray and laboratory studies, including cardiac enzymes, were all within normal limits.
The decision was made to admit the patient for evaluation of his complaints. While awaiting bed assignment, he developed transient chest discomfort, which resolved spontaneously just prior to the second ECG (Figure 2). What test would you recommend for this patient in light of his dynamic ECG changes? See p. 18.