271 A 25-year-old man of Pakistani origin born in the United Kingdom was admitted with a 3-day history of chest tightness and palpitations. The chest tightness was central and heavy in nature with no radiation. Palpitations were regular, and both symptoms occurred in paroxysms of up to 10 seconds. He had never experienced these symptoms before. He had a medical history of well-controlled asthma on β-adrenergic agonist and steroid inhalers, and he was morbidly obese with a body mass index of 43 kg/m. He smoked 2 cigarettes per day and denied consuming alcohol or illicit drugs. He lived with his parents and worked as the manager of an online retail company. His mother had suffered a previous transient ischemic attack; his father had a myocardial infarction in his 40s and was treated for pulmonary tuberculosis in 1985.