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An Older Patient With Chest Pain—Diagnostic Traps

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JAMA Internal Medicine

Published Online: September 25, 2023

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Ziheng Jia, BS¹;

Tong Liu, MD, PhD¹;

Jingjin Che, MD, PhD¹

Author Affiliations

¹Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China

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A patient in their 70s presented to the emergency department (ED) with 2 hours of persistent chest pain accompanied by shortness of breath. The patient’s medical history was notable for hypertension, kidney transplantation due to bilateral kidney trauma, and long-term treatment with cyclosporine, mycophenolate mofetil, and prednisone acetate. Two months before, the patient had been hospitalized for SARS-CoV-2 infection for 1 month. Physical examination on arrival showed pulse rate of 102 beats per minute, respiratory rate of 25 breaths per minute, blood pressure of 135/78 mm Hg, and normal auscultation of the chest. The patient’s cardiac troponin I (cTnI) level was 2.62 ng/mL (reference, <0.16 ng/mL) and N-terminal pro−b-type natriuretic peptide was 1468 ng/L (reference, <125 ng/L). Findings of a 12-lead electrocardiogram (ECG) are shown in the Figure, A.

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A patient in their 70s presented to the emergency department (ED) with 2 hours of persistent chest pain accompanied by shortness of breath. The patient’s medical history was notable for hypertension, kidney transplantation due to bilateral kidney trauma, and long-term treatment with cyclosporine, mycophenolate mofetil, and prednisone acetate. Two months before, the patient had been hospitalized for SARS-CoV-2 infection for 1 month. Physical examination on arrival showed pulse rate of 102 beats per minute, respiratory rate of 25 breaths per minute, blood pressure of 135/78 mm Hg, and normal auscultation of the chest. The patient’s cardiac troponin I (cTnI) level was 2.62 ng/mL (reference, <0.16 ng/mL) and N-terminal pro−b-type natriuretic peptide was 1468 ng/L (reference, <125 ng/L). Findings of a 12-lead electrocardiogram (ECG) are shown in the Figure, A.

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Article Information

Corresponding Authors: Jingjin Che, MD, PhD, (jingjinche@aliyun.com) and Tong Liu, MD, PhD (liutongdoc@126.com), Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, No. 23 Pingjiang Rd, Hexi District, Tianjin 300211, China.

Published Online: September 25, 2023. doi:10.1001/jamainternmed.2023.2461

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was funded by the National Natural Science Foundation of China (No. 82170327 to T.L.) and Tianjin Key Medical Discipline (Specialty) Construction Project (No. TJYXZDXK-029A).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors thank Ms Nan Zhang, BS, (Second Hospital of Tianjin Medical University) for helpful comments; she was not compensated.

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 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.