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Intermittent Chest Pain in a 46-Year-Old Patient

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 46-year-old man with no significant medical history presented to the emergency department (ED) 6 hours after a 20-minute episode of chest pain and diaphoresis that occurred at rest and resolved spontaneously. Two days earlier, he reported a similar 20-minute episode of chest pain and diaphoresis. The patient currently smoked 30 cigarettes per day and had a 20 pack-year history of smoking. He was taking no daily medications and had no family history of cardiovascular disease. On admission to the ED, the patient was asymptomatic. Blood pressure was 102/74 mm Hg, heart rate was 84/min, and oxygen saturation was 100% on room air. His physical examination results were unremarkable. Laboratory testing produced the following results: troponin T, 16 ng/mL (reference, <14 ng/mL); creatine kinase (CK), 82 U/L (1.37 µkat/L) (reference, <190 U/L [<3.17 µkat/L]); CK-MB, 16 U/L (reference, <24 U/L); low-density lipoprotein (LDL) cholesterol, 106 mg/dL (2.75 mmol/L) (reference, <130 mg/dL [<3.37 mmol/L]); and high-density lipoprotein (HDL) cholesterol, 38 mg/dL (0.98 mmol/L) (reference, >35 mg/dL [>0.91 mmol/L]). His initial electrocardiogram (ECG) is shown in Figure 1.

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A 46-year-old man with no significant medical history presented to the emergency department (ED) 6 hours after a 20-minute episode of chest pain and diaphoresis that occurred at rest and resolved spontaneously. Two days earlier, he reported a similar 20-minute episode of chest pain and diaphoresis. The patient currently smoked 30 cigarettes per day and had a 20 pack-year history of smoking. He was taking no daily medications and had no family history of cardiovascular disease. On admission to the ED, the patient was asymptomatic. Blood pressure was 102/74 mm Hg, heart rate was 84/min, and oxygen saturation was 100% on room air. His physical examination results were unremarkable. Laboratory testing produced the following results: troponin T, 16 ng/mL (reference, <14 ng/mL); creatine kinase (CK), 82 U/L (1.37 µkat/L) (reference, <190 U/L [<3.17 µkat/L]); CK-MB, 16 U/L (reference, <24 U/L); low-density lipoprotein (LDL) cholesterol, 106 mg/dL (2.75 mmol/L) (reference, <130 mg/dL [<3.37 mmol/L]); and high-density lipoprotein (HDL) cholesterol, 38 mg/dL (0.98 mmol/L) (reference, >35 mg/dL [>0.91 mmol/L]). His initial electrocardiogram (ECG) is shown in Figure 1.

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Article Information

Corresponding Author: Christian Oeing MD, Department of Internal Medicine and Cardiology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany (christian.oeing@charite.de).

Published Online: October 31, 2022. doi:10.1001/jama.2022.19443

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Zhou  L , Gong  X , Dong  T ,  et al.  Wellens’ syndrome: incidence, characteristics, and long-term clinical outcomes.   BMC Cardiovasc Disord. 2022;22(1):1-8. doi:10.1186/s12872-022-02560-6PubMedGoogle ScholarCrossref
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Kobayashi  A , Misumida  N , Aoi  S , Kanei  Y .  Prevalence and clinical implication of Wellens’ sign in patients with non-ST-segment elevation myocardial infarction.   Cardiol Res. 2019;10(3):135-141. doi:10.14740/cr856PubMedGoogle ScholarCrossref
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Rhinehardt  J , Brady  WJ , Perron  AD , Mattu  A .  Electrocardiographic manifestations of Wellens’ syndrome.   Am J Emerg Med. 2002;20(7):638-643. PubMedGoogle ScholarCrossref
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Arshad  S , Ferrick  NJ , Monrad  ES ,  et al.  Prevalence and association of the Wellens’ sign with coronary artery disease in an ethnically diverse urban population.   J Electrocardiol. 2020;62:211-215. PubMedGoogle ScholarCrossref
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Avram  A , Chioncel  V , Iancu  A ,  et al.  Wellens sign: monography and single center experience.   Maedica (Bucur). 2021;16(2):216-222.PubMedGoogle Scholar
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Migliore  F , Zorzi  A , Marra  MP ,  et al.  Myocardial edema underlies dynamic T-wave inversion (Wellens’ ECG pattern) in patients with reversible left ventricular dysfunction.   Heart Rhythm. 2011;8(10):1629-1634. doi:10.1016/j.hrthm.2011.04.035PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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