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Symptoms: Chest Pain with ECG Changes

Harrigan, Richard MD; Chan, Theodore MD; Brady, William MD

Cases in Electrocardiography

Dr. Harrigan is an associate professor of emergency medicine and the associate research director in the department of emergency medicine at Temple University Hospital and School of Medicine in Philadelphia, Dr. Chan is an associate professor of clinical medicine, emergency medicine, the director of CQI, and the associate medical director of the department of emergency medicine at the University of California, San Diego, Dr. Brady is an associate professor and the vice chairman of the department of emergency medicine at the University of Virginia School of Medicine in Charlottesville.

Figure

Figure

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.

Figure 1

Figure 1

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.

Figure 2

Figure 2

© 2004 Lippincott Williams & Wilkins, Inc.