Baylor University Medical Center Proceedings October 2017 - 439

Listen to the patient!
D. Luke Glancy, MD

44-year-old male cigarette
smoker with an elevated
serum cholesterol level and
a family history of coronary
artery disease experienced nocturnal chest pain. The following day
he went to see a cardiologist. Five
years earlier, this cardiologist had
evaluated the patient for chest pain
with an electrocardiogram (ECG)
and blood tests and told him he was
okay. The cardiologist scheduled the
patient for a future stress test, but
this time did not do an ECG, even
at the patient's request.
The patient had more chest pain
that night and the following day went
to a chiropractor who gave him an
"adjustment" and recorded an ECG
(Figure 1), which the chiropractor interpreted as normal. The next day the
patient had worse and more prolonged
chest pain and went to the hospital,
where an ECG showed an acute anterolateral myocardial infarct (Figure 2).
The serum creatine kinase peaked at
3148 U/L (reference, 24-200) with
an MB fraction of 130.4 (reference, Figure 1. Electrocardiogram recorded in the chiropractor's office in a 44-year-old man with recurrent episodes of
0-44). The serum troponin I peaked chest pain showed terminal T-wave inversion in leads V1-V4 and aVL indicating severe narrowing high in the left
anterior descending coronary artery, the so-called Wellens warning.
at 41.50 ng/mL (reference, 0-0.60).
Cardiac angiography revealed marked hypokinesis of the disand reversed saphenous vein grafts anastomosed to the distal left
tal one-half of the anterolateral wall of the left ventricle with an
anterior descending and the distal right arteries.
akinetic apex and a left ventricular ejection fraction of 45% (referAs described by Wellens and his associates, terminal
ence, ≥55%). Coronary arteriography showed a normal left main
T-wave inversion in the anterior precordial leads, as seen in
artery; subtotal occlusion of the left anterior descending artery
Figure 1, predicts critical narrowing high in the left anterior
distal to the ﬁrst septal perforating branch with TIMI grade 1 ﬂow
descending artery in patients, such as this man, with impendand distal disease; 80% narrowing of the proximal portion of the
ing myocardial infarction (1). Unfortunately, the patient's
right artery with a 50% narrowing in its middle portion; and only
minimal irregularities in the left circumﬂex artery. Three days after From the Section of Cardiology, Department of Medicine, Louisiana State
angiography, the patient underwent a coronary arterial bypass
University Health Sciences Center, New Orleans, Louisiana.
operation with the left internal mammary artery anastomosed
Corresponding author: D. Luke Glancy, MD, 1203 West Cherry Hill Loop, Folsom,
LA 70437 (e-mail: dglanc@lsuhsc.edu).
to the proximal portion of the left anterior descending artery,
Proc (Bayl Univ Med Cent) 2017;30(4):439-440

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