In this issue of JAMA, Yackee et al1 describe a patient with a chunk of steak impacted in the esophagus. As is so often the case in medicine, the diagnosis was correctly made by taking a careful history, so neither the cause nor the solution of this patient's immediate problem was particularly noteworthy. Our interest in this case rests in the patient's electrocardiogram, which was abnormal on presentation and reverted to normal on relief of the impaction. This raised three questions. Was the electrocardiogram suggestive of ischemia? Did the patient have myocardial ischemia in addition to esophageal impaction? If not, how did disease in the esophagus cause electrocardiographic abnormalities?
As with many diagnostic tests, electrocardiographic evidence of coronary artery disease is based upon probability. For example, the finding of Q waves of a certain duration and amplitude in a specific lead in a defined population has a certain sensitivity