November 20, 2024

A 60-year-old woman with a history of hypertension and diabetes

By Med-Challenger · 1 minute read

A 60-year-old woman with a history of hypertension and diabetes presents to you after intermittent episodes of chest pain during the past few weeks. She tells you that she is currently free of chest pain. You decide to obtain electrocardiography (ECG; see Figure).

image (23) Figure. Wellens syndrome. Accessed December 21st, 2016.

Based on the findings on ECG, what is the most likely diagnosis?

coronary vasospasm caused by cocaine abuse
ischemia in the left anterior descending artery distribution
myocarditis
pulmonary hypertension

The correct answer is:

ischemia in the left anterior descending artery distribution

This patient has an abnormal electrocardiogram characterized by symmetrical T-wave inversions greater than 0.2 mv (2 mm) across the precordium, strongly suggestive of myocardial ischemia in the distribution of the left anterior descending artery. These findings carry the name of Wellens Syndrome, after the doctor who first discovered them.

Coronary vasospasm presents with localized ST segment elevation on ECG, depending on the areas of the heart affected. The features of myocarditis can be variable and include sinus tachycardia, QRS/QT prolongation, diffuse T wave inversion, ventricular arrhythmias, and AV nodal conduction abnormalities.

Typical ECG findings in a patient with pulmonary hypertension include right axis deviation, right ventricular and atrial enlargement, and a right ventricular strain pattern showing ST and T wave changes across the anterior precordium.

References:

Jackson MWP, Williams PD. Cocaine-Induced Coronary Vasospasm Using Optical Coherence Tomography Imaging to Guide Management. JACC Cardiovasc Interv. 2016;9(3):e27-e28.

Little WC, Oh JK. Pericardial Diseases. Book Chapter in Goldman-Cecil Medicine, 77, 483-492.e1.

McLaughlin V. Pulmonary Hypertension. Book Chapter in Goldman-Cecil Medicine, 68, 397-404.e2.

Brown AL, et al. Preventive cardiology and ischemic heart disease. In: Foster C, et al, eds. The Washington Manual of Medical Therapeutics. 33rd ed., 2010: 65-154.

From Mattingly BB. Wellens syndrome. Accessed February 8, 2016.

Stolker JM. Ischemic heart disease. In: DeFer TM, et al, eds. The Washington Manual of Outpatient Internal Medicine. 1st ed., 2010: 65-94.

This question appears in Med-Challenger FNP Exam Review with CME

Try for free and save. Ace your exams and meet your CME/MOC requirements for just $19 a month!

No matter your program, no matter the size, Med-Challenger for Groups and Institutions can better prepare your program or group, fulfill industry requirements, and increase test scores.