Endgames Case Report

Chest pain and ST elevation

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e4323 (Published 27 June 2012) Cite this as: BMJ 2012;344:e4323
  1. Stephen P Page, electrophysiology registrar1,
  2. Andrew Archbold, consultant cardiologist2,
  3. Dominic J Abrams, consultant electrophysiologist1
  1. 1Inherited Arrhythmia Service, St Bartholomew’s Hospital, London EC1A 7BE, UK
  2. 2Department of Cardiology, London Chest Hospital, London
  1. Correspondence to: S Page stephen.page{at}bartsandthelondon.nhs.uk

A 53 year old Vietnamese man developed chest pain at rest and dialled the emergency services. The ambulance service identified ST elevation on 12 lead electrocardiography (ECG) and according to local protocol brought him direct to our cardiac centre with a suspected ST elevation myocardial infarction. On arrival he reported a three hour history of central chest pain without radiation or associated symptoms. He was a current smoker but had no other risk factors for coronary artery disease. Examination was unremarkable and an ECG was performed on arrival. In lead V1 there was 2 mm of coved J point elevation, with an inverted T wave. In V2 there was 4 mm of J point elevation, with a saddle shaped ST segment and an upright T wave. In V3 the J point, ST segment, and T wave were within normal limits. He underwent immediate coronary angiography, which showed mild atheroma in the left anterior descending artery, but no obstructive lesions, and transthoracic echocardiography showed normal cardiac structure with good biventricular function.

Overnight he developed a productive cough associated with a fever. Serial ECGs were recorded while he was febrile and showed 3 mm of coved J point elevation in lead V1 and 5 mm of coved J point elevation in V2, with associated T wave inversion.

On further questioning he admitted to a history of well tolerated intermittent palpitations of up to an hour’s duration. His father had died suddenly and unexpectedly by falling from a bridge, but …

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