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Chest Pain, Dyspnea, and a Negative Stress Test in a 46-Year-Old Man


The patient drove himself to the ED after experiencing symptoms while playing basketball. He has a history of anxiety, but is this more than a case of nerves over a missed foul shot?

Managing acute coronary syndrome

Figure 1. ECG tracing obtained on admission to emergency department.

A 46-year-old man with a history of anxiety and chest pain and a family history of hyperlipidemia drives himself to the emergency department after experiencing non-pleuritic, non-radiating chest pain and dyspnea while playing basketball about 30 minutes earlier. He states he recently had a negative stress test, but this chest tightness feels worse than what he has experienced in the past and is lasting longer.

On physical examination he is hyperventilating at a rate of about 32 breaths/min. Blood pressure is 143/98 mm Hg, pulse, 109; and pulse oximetry is 100% on room air. He is still sweaty but his skin is warm. His lung sounds and heart sounds are both normal except for rate. He has no edema and symmetric pulses in all extremities without delay. The rest of his physical exam is normal.

His ECG is shown in Figure 1, at right (click on image to enlarge).

Which of the following should you do next?A. Give aspirin PO   

B. Start lorazepam IV

C. Give nitroglycerine SL     

D. Perform serial ECGs

E. Activate the cath lab  

For answer and discussion, please click here.

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