A 31-year-old woman presents to the emergency department (ED) for one week of episodic, non-pleuritic, non-exertional chest pain. She states she has between 5 to 10 episodes per day, each lasting about 2 to 3 minutes. The pain is severe and radiates to her back, arms, and jaw and seems to occur more frequently when she is lying down. Her regular doctor started her on an antacid 2 days ago but she has noticed no improvement. If anything, she states, the episodes are lasting longer today, especially the most recent one, which lasted approximately 20 minutes. Her own medical history is noncontributory but there is a family history of coronary disease, though no early coronary disease. She does not smoke tobacco and denies illicit drug use.
Examination: Vital signs are normal, including bilateral BP. Head and neck exam is also normal. Lungs are clear and heart sounds are regular with no appreciable murmur. There is no edema and peripheral pulses are intact.
Initial impression: Esophageal spasm
Initial testing: Chest x-ray is normal; ECG tracing is shown at right (please click on image to enlarge).
1. How do you interpret the ECG findings?
2. What should you do next?
Please click “next” below for answers and discussion.