Acute coronary syndrome in a patient with coexistent conduction abnormality

A 46-year-old man had a 1-week history of exertional chest tightness and dyspnea. His symptoms became especially prominent while shoveling snow and he presented to the emergency department. He was free of pain at the time of initial presentation and denied any pain at rest (Fig. 1). One hour after reaching the emergency room his pain recurred and he became hypotensive and a second ECG was obtained (Fig. 2). Past history was negative for hypertension, diabetes, and dyslipidemia, but he admitted to rare checkups. He had one presumed vasovagal episode years before, having passed out while laughing forcefully. There was a remote history of pyloric stenosis and abdominal hernia repair.