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Challenges in Clinical Electrocardiography |

A Rare Cause of Chest Pain and Ventricular Fibrillation

P. Elliott Miller, MD1; Matthew J. Czarny, MD2; M. Roselle Abraham, MD2
[+] Author Affiliations
1Osler Medical Service, Johns Hopkins School of Medicine, Baltimore, Maryland
2Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
JAMA Intern Med. 2014;174(7):1173-1175. doi:10.1001/jamainternmed.2014.1809.
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A man in his late 50s presented with sudden-onset chest pain followed by a shock from his implantable cardioverter-defibrillator (ICD). His history included a cardiac arrest secondary to ventricular fibrillation resulting in ICD implantation 1 year prior, chronic obstructive pulmonary disease, hypertension, and active tobacco and alcohol abuse. There was no history of hyperlipidemia or family history of coronary artery disease. His initial symptom was paresthesia in the right hand, which progressed up his arm and was followed by chest tightness and dyspnea. Notably, he had 6 similar presentations in the preceding year, but myocardial infarction had been ruled out by serial electrocardiograms (ECGs) and cardiac biomarker results on all occasions.

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Figure 1.
Electrocardiogram Showing ST-Segment Elevations

ST-segment elevations can be seen in the inferior (II, III, and aVF), posterior, and lateral precordial leads with ST-segment depressions in I and aVL.

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Figure 2.
Coronary Angiography

A, Diffuse coronary artery vasospasm before administration of intracoronary nitroglycerin. B, Relief of vasospasm by intracoronary nitroglycerin therapy.

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Figure 3.
A Representative Implantable Cardioverter-Defibrillator Interrogation Showing Ventricular Fibrillation (VF) Followed by a Shock and Return to Sinus Rhythm

The arrowhead shows the transition from VF to sinus rhythm. VS indicates ventricular sensed; VT, ventricular tachycardia.

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