Endgames Case Review

A man with chest pain and acute ST elevations on electrocardiogram

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2198 (Published 18 May 2017) Cite this as: BMJ 2017;357:j2198
  1. Erica O Miller, fellow1,
  2. Vijay K Krishnamoorthy, associate professor1,
  3. Frederick S K Ling, professor1,
  4. Abhishek Chaturvedi, assistant professor2,
  5. Scott J Cameron, assistant professor1 3
  1. 1Department of Medicine, Division of Cardiovascular Disease, University of Rochester, New York, USA
  2. 2Department of Imaging Sciences, University of Rochester, New York
  3. 3Aab Cardiovascular Research Institute, University of Rochester, New York
  1. Correspondence to Scott J Cameron scott_cameron{at}urmc.rochester.edu

A 45 year old man with a history of dyslipidemia presented to the emergency department with chest pain. He was awakened from sleep one hour earlier with burning, pressure-like substernal chest pain radiating to his left arm with associated nausea. He denied dyspnoea, diaphoresis, or lightheadedness. The pain was constant, not worse with exertion, and not relieved by an antacid medication. He reported good health throughout his life, managing his dyslipidemia with diet and exercise and he did not take prescription medications. The man’s family history was notable for coronary artery disease in his father. He denied smoking cigarettes and using any drugs, and was quite physically active in martial arts. His blood pressure was 160/101 mm Hg on arrival, and his cardiovascular and respiratory examinations were unremarkable. A 12 lead electrocardiogram (fig 1) and an emergent coronary angiogram were taken. Contrast ventriculography showed preserved left ventricular ejection fraction with hypokinesis of the inferior left ventricular wall. Serum creatine kinase was elevated to 1942 U/L (reference range 47-171 U/L) the morning after presentation.

Fig 1 Presenting electrocardiogram

Questions

  1. What is the most likely diagnosis?

  2. What is the underlying aetiology?

  3. How would you manage this patient?

1. What is the most likely diagnosis?

Short answer

The electrocardiogram shows inferior ST segment elevations consistent with an acute myocardial infarction. Coronary angiography shows coronary artery aneurysm of the right coronary artery with acute intracoronary thrombosis.

Discussion

The electrocardiogram shows sinus arrhythmia with first degree heart block, ST segment elevations in all three inferior leads (II, III, and aVF), and ST segment depressions in the right precordial leads (V1 and V2). Inferior ST segment elevations are generally observed with acute inferior wall …

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