JAMA Clinical Challenge

Chest Pain and an Angiographic Abnormality

Image of A, Coronary angiogram. B, Detail of mid-distal left anterior descending artery

Vijaya L. Rao, MD
Vibhav Rangarajan, MD
A 55-year-old man is admitted from the emergency department with1 month of progressively worsening dyspnea and exertional angina. His medical history is significant for hypertension, hyperlipidemia, and gastroesophageal reflux disease. He denies tobacco use, heavy alcohol consumption, illicit drug use, or blunt trauma to the chest. He takes celecoxib for knee pain and swelling. His family history reveals that his mother died of complications of scleroderma. Acute coronary syndrome is ruled out with serial measurement of cardiac biomarker levels and serial electrocardiograms. An electrocardiogram reveals Q waves and poor R-wave progression in the anterior leads and T-wave flattening in the inferior leads. Transthoracic echocardiography reveals an ejection fraction of 45%, left ventricular hypertrophy, mild hypokinesis of the left ventricle, and akinesis of the apical septal segment. The exertional angina resolves over the next day, and the patient remains hemodynamically stable. Results of coronary angiography are shown in the Figure.

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Author Affiliations: Drs Rao (vijaya.l.rao@gmail.com) and Rangarajan are affiliated with the Department of Internal Medicine, Loyola University Medical Center, Maywood, Illinois.