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ECG Quiz Question

Chest Pain and a 'Normal' Exercise ECG in a 44-Year-Old Runner

John D. Cantwell, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 9 - SEPTEMBER 2021


A 44-year-old man was evaluated because of new-onset chest pain.

The patient reported that 4 days earlier, at a stressful out-of-town business meeting, he had experienced anterior chest pain while sitting. It improved when he lay on his side. The pain was steady for 1 hour, then intermittent for several hours. The patient went the same day to an ambulatory care clinic, where an electrocardiogram (ECG) and chest x-ray were said to be normal, and an antacid was prescribed. The chest pain recurred the following day while he was running on a treadmill, but did not return during a 30-minute run the morning I initially examined him.

Six days before the pain first occurred, the patient had had a flu-like illness with nasal drainage, a mild cough, and yellowish phlegm. He did not have fever or chills. Amoxicillin trihydrate seemed to alleviate most of his symptoms.

He typically ran 2 miles in 25 minutes about five times a week and lifted weights for 1 hour once a week. He had smoked cigarettes for 2 or 3 years and had quit 22 years ago. He followed a low-fat diet. He had no family history of early coronary heart disease. His mother had hypertension; she had undergone repair of a thoracic aneurysm in her 60s. A 47-year-old sister had hypertension.

On physical examination, his blood pressure was 138/90 mm Hg in both arms, and his pulse was regular at 80 per minute. His cardiopulmonary assessment was normal, and his peripheral pulses were symmetrical.

Laboratory data showed an elevated total cholesterol level of 236 mg/dL, a triglyceride level of 138 mg/dL, high-density lipoprotein of 47 mg/dL, and low-density lipoprotein of 183 mg/dL.

His resting ECG is shown in figure 1. An electron beam computed tomography scan (EBCT) was obtained; the patient's calcium score was 19.2, and a mild amount of calcium was seen in the left anterior descending coronary artery.

[Figure 1]

Three days after the tests mentioned above, the patient completed 12.5 minutes on the Bruce protocol treadmill test, reaching a peak heart rate of 150 beats per minute. His blood pressure peaked at 152/86 mm Hg, then fell to 128 mm Hg systolic at the end of the test. At 10.9 minutes, he reported midchest discomfort, which subsided 5 minutes postexercise.

An ECG obtained immediately postexercise (figure 2) was read as normal. Do you agree? What further tests, if any, would you recommend? Does his EBCT scan, with a calcium score of 19.2, concern you or reassure you?

[Figure 2]

Dr Cantwell is a cardiologist at Cardiology of Georgia, PC, and clinical professor of medicine at Morehouse School of Medicine, both in Atlanta. He is an editorial board member of The Physician and Sportsmedicine. Address correspondence to John D. Cantwell, MD, Cardiology of Georgia, PC, 95 Collier Rd NW, Suite 2075, Atlanta, GA 30309.


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