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Challenges in Clinical Electrocardiography
May 2016

Electrocardiography Evolution in a Woman Presenting With Alcohol Withdrawal Seizures and Cocaine Use

Author Affiliations
  • 1Department of Medicine, University of California, San Francisco
  • 2Division of Cardiology, Department of Medicine, San Francisco General Hospital, San Francisco, California
JAMA Intern Med. 2016;176(5):693-695. doi:10.1001/jamainternmed.2016.0278

A postmenopausal woman with a history of alcohol abuse complicated by withdrawal seizures (last occurring 4 months prior), crack cocaine abuse, and depression was brought into the emergency department for altered mental status after 3 witnessed seizures. Her partner stated that the evening prior, she did not drink alcohol but did snort cocaine.

She was afebrile and arousable but not oriented. Her heart rate was 85 beats per minute and blood pressure was 135/90 mm Hg. Cardiopulmonary examination results were within normal limits, and neurologic examination revealed no focal deficits. Results from complete blood cell count and electrolyte panel were normal, and a urine toxicology screen was positive for cocaine. Results from a noncontrast head computed tomographic (CT) scan were normal. Her initial electrocardiography (ECG) test showed normal sinus rhythm with Q waves in the anterior leads and early repolarization (Figure, A). Over the next 7 hours, her mental status improved, and she remained seizure-free. The patient was about to be discharged when ST-segment elevations were noted on the MCL3 telemetry lead. A 12-lead ECG demonstrated ST-segment elevations in leads V3 to V6 (Figure, B). On further questioning, the patient reported a 1-day history of mild, constant, nonradiating, non–nitroglycerin-responsive chest ache at rest but denied exertional chest pain. Her troponin level, drawn when the ST-segment elevations were noted, was 3.2 ng/mL.

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