Caucasian man with acute coronary syndrome and peculiar ECG

Dr. Andrés R. Pérez Riera
Brazil

Case presentation

A 61-year-old Caucasian male presented to the emergency room with severe crushing chest pain of 3-hour duration. The pain was retrosternal, was crushing, and was associated with profuse cold sweating and vomiting. There was no radiation of pain, breathlessness, or nausea. He is a known hypertensive on olmesartan 40mg + hidroclorotiazide 12,5mg + orlistat 120 mg 3x/day. He has centripetal severe obesity class II (BMI 38). Waist-to-hip ratio > 0.95. He did not have any other risk factors for coronary artery disease (CAD). He was not a smoker, and there was no family history of CAD.

The admission ECG in showed particular characteristics (ECG1). On physical examination, his blood pressure was 120/80 mm of Hg and heart rate was 52/minute, and there were no abnormal findings on physical examination.

Questions

Which is the electrocardiographic particular diagnosis?
Which is the culprit artery?
Which is the appropriate approach?

Apresentaçao do caso

Homem branco de 61 anos se apresentou na sala de emergência com dor intensa retroesternal com caráter de esmagamento, sem irradiação iniciada havia 3 horas atrás. A dor estava associada com sudorese fria profusa e vômitos. Não estava associada a falta de ar ou náusea. Referia ser hipertenso em uso regular de olmesartan 40mg + hidroclorotiazida 12,5mg + orlistat 120 mg 3x/dia.

Obeso centrípeto grave grau II (IMC 38). Relação cintura/cadeira > 0,95. Não tem outros fatores de risco para doença arterial coronariana (DAC). Não é fumante, e não tem história familiar de DAC.
O ECG de admissão possui características particulares (ECG1).
Ao exame físico, pressão arterial de 120/80 mm Hg e freqüência cardíaca 52 bpm, e não foram achadas outras anormalidades.