Crushing angina

Abstract

In October, 2009, a 51-year-old man was referred to our clinic after developing exertional chest pain. 3 weeks earlier his motorbike had fallen onto his chest while he was underneath repairing it. Previously, he had an unlimited exercise tolerance, cycling several miles a week. Immediately after the event, he denied chest pain apart from mild bruising. However, when cycling the next day, he developed central chest tightness radiating to his left arm with shortness of breath. This resolved 10 minutes after stopping exercise. Similar chest pain subsequently occurred on walking more than 200 metres. His risk factors for coronary artery disease were hypercholesterolaemia (fasting cholesterol 7·2 mmol/L) and being an ex-smoker (17 pack-year history). He had no other relevant medical history and was on no medication. On examination, he looked well. His pulse was 47/min and regular, blood pressure was 120/80 mm Hg, and oxygen saturations were 98% on room air. There was no bruising on his chest wall and no reproducible chest tenderness. Cardiovascular examination showed a normal jugular venous pressure, a non-displaced apex beat, and normal heart sounds without murmurs or a pericardial rub. Respiratory and abdominal examinations were unremarkable. An electrocardiogram (ECG) showed sinus rhythm at a rate of 49 with biphasic T-waves in V2, V3, and I and an inverted T-wave in aVL (figure A). (A) Biphasic T-waves in I, V2, and V3, and an inverted T-wave in aVL. (B) LAD artery stenosis; (C) resolution post-angioplasty.