A man in his 80s who developed left pleuritic chest pain presented to the emergency department (ED). His medical history was remarkable for atrial fibrillation with slow ventricular response, and a VVI pacemaker lead (tined) had been placed at the right ventricular apex in 1999. In 2010, he underwent bioprosthetic aortic valve replacement and mitral valve repair for severe aortic regurgitation and moderate mitral regurgitation. Before his presentation, a sudden pain developed at the apical area of the heart; diaphoresis was observed and the chest pain worsened during inspiration. Initial vital signs at the ED were as follows: blood pressure, 126/70 mm Hg; heart rate, 70 beats/min; respiratory rate, 16/min; body temperature, 36.9° C; and blood oxygen saturation, 98%. Reports of a previous electrocardiogram (ECG; Figure 1A) and that at presentation (Figure 1B) were obtained. Cardiac biomarkers were negative, and no pericardial effusion was observed in echocardiographic and computed tomographic (CT) scans. Pulmonary thromboembolism and acute aortic dissection were ruled out in the contrast-enhanced CT scan. The patient was admitted for further evaluation.
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Hirata K, Takahashi T, Nakazato J. Chest Pain and Electrocardiographic Changes in a Patient With a VVI Pacemaker. JAMA Intern Med. Published online September 03, 2019. doi:10.1001/jamainternmed.2019.3002
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