Case vignette

A 21-year-old man presents to the emergency department with complaints of intermittent chest pressure for 2 days. He has no family history of coronary artery disease, early myocardial infarction (MI) or sudden death. Two days ago, while getting ready for bed, he had a vague pressure sensation in his chest that was non-radiating without shortness of breath, diaphoresis or nausea. When he woke up the following morning, he had similar pain but this time with slightly increased intensity. He presented to the emergency department where an ECG (see figure 1) and a chest x-ray were taken. He was discharged home with a diagnosis of musculoskeletal chest pain. Later that evening, he had a recurrent episode of chest pain with diaphoresis, shortness of breath and nausea. On examination, the patient is diaphoretic with vital signs showing a heart rate of 68 beats/min, blood pressure of 132/59 mm Hg, respiratory rate of 18 breaths/min and pulse oximetry of 100% saturation. Examination reveals lungs that are clear to auscultation and no murmur, gallops or rubs on cardiac examination. An ECG is obtained (see figure 2).

Key questions

1. Before looking at the ECGs, what is your differential diagnosis? …