Here is a case presentation in cardiology for educational purpose for young cardiologist, emergency physicians and internists.

1. Cardiology Case

2. History
• A 39- year-old south Asian man presented to
the ER with a 3-week history of chest pain.
This pain is burning, central at the lower chest
and was not clearly associated with exertion.
It did not radiate and there was no associated
symptoms. He smokes 20 cigarettes per day.
• The was no past medical history.
• His father died at the age of 41 with a heart
attack. There is family history of diabetes.

3. History
• He had presented twice in the preceding 3
weeks. On both previous occasions the ECG
and cardiac enzymes was reported to be
normal.
• On the second occasion the patient was
diagnosed to have GERD and was prescribed
ranitidine 150mg bd.

4. Examination
• The patient was anxious but pain free at the
time of exam.
• Pulse:75 bpm regular
• BP: 145/80 mmHg
• O2 Saturation: 98% on room air
• Resp. rate: 14 breath/min

5. Examination
• Cardiovascular exam was unremarkable.
• Chest pain was not reproduced with manual
pressure.

6. ECG

7. • Cardiac Troponin I measurements on
admission and 12 hours after were normal.

8. Question 1
What is the differential
diagnosis for this presentation?

9. DD of chest pain
Source Type Radiate Tender Posture Breath food NTG
movement
ACS Visceral Lt arm - - - - +
neck jaw
Dissecting Visceral Back or as - - - - +/-
aneurysm ACS
Pericardial/ Somatic - +/- + + - -
Pleural
Lung tissue Visceral/ - - - + - -
somatic
Pneumothorax Visceral/ - - - - - -
somatic
MSK Somatic - + + + - -
Nerve Somatic/ +/- + +/- - - -
neuropathic
GI Visceral + +/- - - + +/- 

10. • In this case, the pain is not consistent with any
of the common etiologies.
• In 1 of each 5 cases diagnosed with ACS, the
patient was initially discharged from ER with
another diagnosis.
• Misdiagnosis is most common in women <55
years, non-cucasians and those with normal
ECG

11. • Atypical presentations of ACS are not
uncommon, particularly in young(25-
40), elderly (>75), diabetics, and women.
• Ischemic pain can be rest
pain, epigastric, stabbing, or with some
pleuritic features.
• ACS can present with increasing dyspnea
without pain.

12. Question 2
• What is the D. D. of the patients ECG?

13. ECG interpretation
• Sinus rhythm at a rate of 66 bpm
• Left axis deviation
• Dominant R-waves in V1-V3
• Low voltage R-waves in inferior and lateral leads.
• T-waves are upright anteriorly and biphasic
laterally

14. DD of Dominant R-wave in V1
1. Right ventricular hypertrophy (the most
common cause).
– Usually associated with repolarization abnormality
causing down sloping ST-segment depression and
T-wave inversion
– Usually associated with right axis deviation

16. 2. Posterior myocardial infarction
– Up right T-waves in V1
– Left axis deviation due to associated inferior MI

18. 3. Right bundle branch block:
– QRS duration is prolonged
– Typical wave form ( rSR’ in V1 and RS in V6)

19. 4. WPW syndrome
– If left sided accessory pathway
– Delta wave is present

20. 5. Incorrect ECG leads placement
6. Dextrocardia
7. Normal variant
8. Rare causes: Duchenne/Becker
myopathy and constrictive pericarditis

21. Question 3
What is the next step in
management for this patient?

22. • This patient most properly has post-
infarction angina after posterior MI
• This patient was referred for coronary
angiography that showed critical
proximal stenosis in dominant right
coronary artery.
• Angioplasty and stenting of RCA was
done with good recovery.