Circulation Cardiovascular Case Series


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 tight-ness 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 2. 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. Dr Lefroy: This young patient presents with recent chest pain and palpitations. The differential diagnosis is wide at this stage; in an older patient, it would be most important to consider and exclude acute coronary syndrome. Although uncommon in younger patients, an acute coronary syndrome can occur in those with traditional risk factors such as smoking , obesity, hypertension, and diabetes mellitus. A number of inherited disorders also predispose to premature coronary artery disease such as familial hypercholesterolemia and factor V Leiden. Other rare causes include spontaneous coronary artery dissection and paradoxical embolism through a patent foramen ovale. It is also important to consider vasospasm from illicit drugs such as cocaine. Myocarditis should also be considered as a differential for this patient. Such patients may present with heart failure, cardiac arrhythmias, or chest pain mimicking acute coronary syndrome. It is also possible that cardiac arrhythmia is the primary pathology with the symptom of chest tightness secondary to tachycardia. Finally, it is important to consider gastric pathology such as gastroesophageal reflux or esophageal spasm in the differential diagnosis. Young patients may also suffer from anxiety related chest symptoms and palpitations with no organic pathology, but this should be a diagnosis of exclusion. On examination, heart sounds 1 and 2 were present with no added sounds. The apex beat was not displaced and jugular venous pressure was not elevated. The chest was clear to auscultation. His abdomen was soft and not tender with no organomegaly. His blood pressure was 113/72 mm Hg , pulse was 93 bpm, oxygen saturation was 96% on air, and temperature …

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