Awfully Young for a Heart Attack
A 35-year-old man comes to the emergency department with a history of frequent visits for exertional chest pain and shortness of breath. He has never been admitted to the hospital previously, but during another recent emergency department visit, he was found to have an elevated N-terminal pro–B-type natriuretic peptide (NT-proBNP) level. He denies diabetes and hyperlipidemia, reports no family history of heart problems, and does not use tobacco or alcohol.
The patient's social history discloses that he is an immigrant from El Salvador, and works as a dishwasher.
On exam, his blood pressure is 105/64 mm Hg and pulse is 84 beats/min and regular. His oxygen saturation by pulse oximetry is 92% on room air. A jugular venous assessment showed that his neck veins are elevated to 13 mm Hg, and he has crackles at both lung bases. His cardiac exam reveals an S1, loud P2 of his second heart sound, and a 3/6 holosystolic murmur at the apex without a diastolic rumble. He has no pitting edema, and his skin is warm, with good pulses.
An ECG is obtained (Figure 1). His troponin level is 0.13 ng/mL, and the NT-proBNP level is 2300 pg/mL.
Figure 1. ECG of patient with bifascicular block.
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