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JAMA Clinical Challenge | Clinician's Corner

Chest Pain and an Angiographic Abnormality

Vijaya L. Rao, MD; Vibhav Rangarajan, MD
JAMA. 2013;309(10):1030-1031. doi:10.1001/jama.2013.1865.
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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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Figure. A, Coronary angiogram. B, Detail of mid-distal left anterior descending artery.
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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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