Case #19 — Osborn Waves: Differential Diagnosis

by Akriti G. Jain, MD, Hammad Zafar, MD, Sanjay Jain, MD, and Jason D’Souza, MD

A 56-year-old man with schizoaffective disorder, type 2 diabetes mellitus, and no cardiac history was sent from a psychiatric facility for evaluation of a left foot wound. He was disoriented to time, place, and person. The patient’s core body temperature was 87.4 °F, and his pupils were equally reactive to light. His left foot had an ulcer with a dirty base and much foreign material, and his 2nd and 3rd toes were black with clear demarcation. Laboratory results included a normal white blood cell count (8 ×10⁹/L, 23% band neutrophils), a hemoglobin level of 7.4 g/dL, normal electrolyte levels except for calcium elevation (11.8 mg/dL; 12.8 mg/dL after correction for albumin), and no detected cardiac troponin. Urine toxicology results were positive for tricyclic antidepressants (TCAs). An electrocardiogram (ECG) showed junctional rhythm with J waves (Osborn waves); a corrected QT interval (QTc) of 468 ms; a PR interval of 188 ms; and a heart rate of 60 beats/min (Fig. 1).

Case #18 — ST-Segment Elevation Soon after Coronary Artery Bypass Grafting

by Sanket Borgaonkar, MD, and Yochai Birnbaum, MD, FACC

A 59-year-old woman with hypertension, hyperlipidemia, and gastroesophageal reflux reported exertional angina that resolved with rest and nitroglycerin. Nuclear stress test results revealed a small, reversible inferior-wall defect and a left ventricular ejection fraction (LVEF) of 0.67. A coronary angiogram showed diffuse 3-vessel disease. The patient underwent elective 4-vessel coronary artery bypass grafting (CABG) with no complications and was extubated the next day. On postoperative day 2, a routine electrocardiogram (ECG) showed an rSr′ pattern in leads V₁ and V₂, and ST-segment elevation (STE) in leads V₂ through V₄ (Fig. 1).

Case #17 — Tachycardia in the Presence of Ventricular Pacing

by Toug Tanavin, MD, Mark Pollet, MD, and Yochai Birnbaum, MD, FACC

A 61-year-old man with coronary artery disease presented with volume overload caused by medication noncompliance. His medical history included percutaneous coronary intervention; ischemic cardiomyopathy (left ventricular [LV] ejection fraction, <0.15); and placement of a biventricular implantable cardioverter-defibrillator (ICD), model and programming unknown. Chest radiographs showed properly positioned ventricular and right atrial leads. Figure 1 shows the patient’s electrocardiogram (ECG) on presentation.

Case #16 — Cocaine-Induced Electrocardiographic Phenomenon

by Sundeep Kumar, MD, Luis Sanchez, MD, Ruthvik Srinivasamurthy, MD, and Patrick F. Mathias, MD, FACC

A 27-year-old white man presented at the hospital after recent cocaine use, reporting intermittent left-sided chest pain, diaphoresis, and dizziness. His vital signs were normal; results of physical examination were not noteworthy. Chest radiographic and cardiac enzyme test results were normal. His urine was positive for cocaine. An electrocardiogram (ECG) during a pain-free state revealed findings not present one month earlier: a prolonged QTc interval, new T-wave inversions, and biphasic T waves in leads V₂ and V₃ (Fig. 1, arrows).