Patients Who Presented With Chest Pain

1. Mr SBS, a 50 year old Malay man, with no known medical illness, chronic smoker with 45 pack years of smoking history, presented to the Emergency Department of HTJ with complaints of sudden onset of central chest pain which came on during rest, was pressing in nature, non-radiating, not aggravated by movement and breathing, not affected by posture, not relieved by rest, pain score of 8/10, 5-6 episodes lasting about 15 minutes, associated with sweating, palpitations, nausea, shortness of breath and dizziness which was preceded by severe generalized headache two days prior. He has had multiple episodes of chest pains preceded by severe headache in the past 4 years but did not seek any medications. He was brought to a private GP by his wife after 1 hour of onset of chest pain, and was found to have sinus bradycardia on electrocardiogram (ECG) with a heart rate of 40-44 beats per minute.

  1. What do you think is the cause of his chest pain?
  2. What could be the reason for his bradycardia?

2. Mr L, a 63-year-old Chinese man, under follow-up at klinik kesihatan for hypertension, dyslipidemia and ischemic heart disease on aspirin, perindopril, bisoprolol and simvastatin, presented with a sudden onset of central chest pain associated with profuse sweating and palpitations which was not relieved with 2 tablets of sublingual GTN. He had no symptoms of heart failure. Angiogram was done 3 years ago which showed 2 vessel occlusions of 65% (no formal report available). He has a strong family history of coronary artery disease, whereby his father died at the age of 55 years after a myocardial infarction and his 2 brothers have CAD for which CABG has been performed.
On examination, he was alert but in pain. Patient was not in shock as apparent from warm peripheries, BP: 146/92 mmHg, Pulse: 90bpm of good volume, and RR:20 breaths/min. SpO2 was 94%. Apex beat was displaced to 1cm lateral to left mid clavicular line at 5th intercostal space indicating cardiomegaly. Other systemic examinations were unremarkable.
Upon investigation, troponin I was raised and ECG showed sinus rhythm with ST elevation of 0.2mV on leads V1, V4, V5 and 0.4mV on leads V2, V3 with hyperacute T wave changes.

  1. What is the cause of his chest pain?
  2. What is the significance of “hyperacute T waves”?

3. Madam ZBD, a 81 years old Malay lady with underlying ischemic heart disease diagnosed last year with ischemic heart disease after an acute episode of myocardial infarction and with hypertension presented with chest discomfort, breathlessness, cough and palpitations for the past one week. On physical examination, her pulse rate was 108 beats per minute, blood pressure was 179/100 mmHg, respiratory rate was 24 breaths per minute with oxygen saturation of 99% on face mask oxygen 5L. She had physical signs of pedal oedema, elevated jugular venous pressure 4cm above sternal angle and on chest examination, the apex beat was deviated and felt over the sixth intercostal space 2cm lateral to midclavicular line and heart sound S3 was heard with bibasal fine lung crepitations.
Electrocardiogram showed left bundle branch block and Q waves in leads V3, V4 with poor R waves progression. Chest radiograph showed cardiomegaly and increased pulmonary vasculatures marking. Echocardiogram found her ejection fraction was less than 40 percent and she had dilated left atrium and ventricle.

  1. What is reason for her breathlessness?
  2. What does the deviated apex beat imply?
  3. What does the third heart sound imply?
  4. Suggest an explanation for her cardiomegaly and dilated left atrium.

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