Well, Doc, My Chest Pain Is All Gone

1Tulane University Health Sciences Center, New Orleans, LA
2Tulane University Health Sciences Center, New Orleans, LA

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 237

Case Presentation:

A 69‐year‐old man with a history of hypertension presented to an outside hospital emergency department (ED) with nonradiating substernal chest pressure that woke him at 2 am. He had experienced such pain before and attributed it to reflux. When the pain remained unchanged hours after omeprazole, he presented to the ED. There, he was diagnosed with non‐ST‐elevation myocardial infarction (NSTEMI) with initial troponin elevated at 0.70 ng/mL and nondiagnostic EKG. He was then transferred to our hospital for further management. On arrival, he was pain free. A repeat EKG revealed biphasic T waves in leads V2 and V3 consistent with Wellens' syndrome. Subsequent left heart catheterization demonstrated 95% left anterior descending (LAD) coronary artery occlusion.

Discussion:

Within the differential diagnoses for chest pain, acute coronary syndrome (ACS) is among the most life‐threatening causes that must be quickly evaluated by the general internist. Therefore, the general internist must be adept at recognizing different presentations of acute coronary syndrome. EKGs often provide the earliest clues during the evaluation of suspected ischemic chest pain. Well‐known EKG patterns suggesting ACS include acute ST elevations, ST depressions, and acute left bundle branch block. When these classic findings are not seen on the initial EKG, it is beneficial to repeat the EKG within 10 minutes in patients with a high clinical suspicion for ACS. Repeat EKG enables a better evaluation of evolving changes and better detection of subtle ischemic findings. Wellens' syndrome is one such subtle finding often unrecognized by clinicians. This ominous pattern of inverted or biphasic T waves in the anterior precordial leads portends a critical LAD stenosis that progresses to extensive anterior wall myocardial infarction. This EKG pattern is characteristically present in the absence of chest pain during the evolution of the MI; this can delay recognition of acute coronary ischemia. Once diagnosed, patients with Wellens' syndrome should be sent for emergency revascularization as with classic STEMI. Without revascularization, these patients frequently develop worsening myocardial infarction, left ventricular dysfunction, and death.

Conclusions:

This case demonstrates the importance of recognizing subtle EKG patterns in acute coronary syndrome. When this diagnosis is suspected in a patient without classic EKG findings, the EKG should be repeated in ten minutes. Once Wellens' syndrome is recognized, the patient, although pain free, must be sent for immediate revascularization.

To cite this abstract:

Adimora‐Nweke D, DeBord J. Well, Doc, My Chest Pain Is All Gone. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 237. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/well-doc-my-chest-pain-is-all-gone/. Accessed March 20, 2019.

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