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Clinical Quiz Question

A 'Sensitive Heart' in a Tennis Player

John D. Cantwell, MD; Charles W. Wickliffe, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 2 - FEBRUARY 2000


A 49-year-old man was evaluated because of exertional chest pain of 1 month's duration that began during vigorous tennis. Initially, the pain was substernal and lasted 1 to 2 minutes. Recurrent episodes were always exercise related, though the activity might be mild, and episodes were relieved by several minutes of rest. At times, the pain radiated to the left side of the neck.

In March 1997, as part of the initial workup, the patient underwent Bruce-protocol treadmill testing. He completed 12 minutes and reached a peak heart rate of 150 beats per minute (85% of age-predicted maximum) and a blood pressure of 170/66 mm Hg (figure 1).

[Figure 1]

He had smoked a pack of cigarettes daily for 20 years. His father had had a heart attack at age 60, and the patient's paternal grandfather died of a probable myocardial infarction in his 40s. His medical history was otherwise unremarkable.

Exertional chest pain persisted, and in December 1997 the patient underwent cardiac catheterization. The coronary arteries were normal, and the left ventricular ejection fraction was normal at 60%. He was advised to stop smoking, which he did, and was given a trial of ranitidine hydrochloride 150 mg twice daily.

His symptoms persisted, and in July 1998, echocardiography was normal. In September 1998 the treadmill ECG was repeated and was unchanged. During the test he developed midchest pain that subsided after several minutes of rest. He was placed on diltiazem 180 mg daily.

When seen in November 1998, he reported that persistent chest pain limited his ability to play tennis or even to play with his 16-month-old son. Sublingual nitroglycerin afforded him limited benefit during his 30-minute walking program.

Laboratory data showed an elevated total cholesterol level of 223 mg/dL, triglyceride level of 115 mg/dL, low-density lipoprotein level of 142 mg/dL, and high-density lipoprotein of 58 mg/dL.

What is your interpretation of the patient's exercise ECG? What is one possible cardiovascular explanation for his exertional chest pain without apparent coronary artery disease?

Dr Cantwell is a cardiologist at Cardiology of Georgia, PC, and Dr Wickliffe is cardiologist and chief of staff at Piedmont Hospital, both in Atlanta. Address correspondence to John D. Cantwell, MD, Cardiology of Georgia, PC, 95 Collier Rd NW, Suite 2075, Atlanta, GA 30309.


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