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Challenges in Clinical Electrocardiography |

Electrocardiography Evolution in a Woman Presenting With Alcohol Withdrawal Seizures and Cocaine Use

Jonathan Chou, MD, PhD1; Lisa R. Beutler, MD, PhD1; Nora Goldschlager, MD1,2
[+] Author Affiliations
1Department of Medicine, University of California, San Francisco
2Division of Cardiology, Department of Medicine, San Francisco General Hospital, San Francisco, California
JAMA Intern Med. 2016;176(5):693-695. doi:10.1001/jamainternmed.2016.0278.
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A postmenopausal woman with a history of alcohol abuse complicated by withdrawal seizures (last occurring 4 months prior), crack cocaine abuse, and depression was brought into the emergency department for altered mental status after 3 witnessed seizures. Her partner stated that the evening prior, she did not drink alcohol but did snort cocaine.

She was afebrile and arousable but not oriented. Her heart rate was 85 beats per minute and blood pressure was 135/90 mm Hg. Cardiopulmonary examination results were within normal limits, and neurologic examination revealed no focal deficits. Results from complete blood cell count and electrolyte panel were normal, and a urine toxicology screen was positive for cocaine. Results from a noncontrast head computed tomographic (CT) scan were normal. Her initial electrocardiography (ECG) test showed normal sinus rhythm with Q waves in the anterior leads and early repolarization (Figure, A). Over the next 7 hours, her mental status improved, and she remained seizure-free. The patient was about to be discharged when ST-segment elevations were noted on the MCL3 telemetry lead. A 12-lead ECG demonstrated ST-segment elevations in leads V3 to V6 (Figure, B). On further questioning, the patient reported a 1-day history of mild, constant, nonradiating, non–nitroglycerin-responsive chest ache at rest but denied exertional chest pain. Her troponin level, drawn when the ST-segment elevations were noted, was 3.2 ng/mL.

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A, Initial electrocardiography (ECG) on presentation demonstrating Q waves in V2 and V3 and early repolarization in V4 (arrowhead); B, ECG demonstrating borderline tachycardia and ST-segment elevations in leads V3 to V6, 7 hours after initial presentation while the patient was asymptomatic; C, ECG demonstrating persistent ST-segment elevations in lead V3, with new T-wave inversions in the lateral leads V4 to V6, 11 hours after initial presentation; D, ECG demonstrating deepening and more diffuse T-wave inversions in V3 to V6 as well as the inferior leads II, III, and aVF, 48 hours after initial presentation. The QTc interval calculated from lead V5 is significantly prolonged at 600 milliseconds.

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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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