A 38 year old man presents with left-sided tightening chest pain for 10 hours, with radiation to the neck. He also experienced a tingling sensation in his left arm and neck, and mild dyspnea and lightheadedness.

His medical history is significant for well controlled hypertension for 5 years. There is an extensive family history of ischemic heart disease, with his mother dying of a myocardial infarction in her early 50s.

He admits to inhaling cocaine and smoking marijuana about 30 minutes before the onset of the pain. He has a history of cocaine use for 10 years.

Select Relevant Investigations
Cardiac Biomarkers


Troponin I: 0.1 ng/mL (<10)
Creatine Kinase (CK): 681 U/L (<200)
CK-MB Fraction: 1% (3-5)


The ECG is in sinus rhythm, with a rate of 90 bpm. There is a complete right bundle branch block, with a PR interval of 0.28 seconds. There are ST segment depressions and T-wave inversions in the leads V1-V3. Serial ECGs show no dynamic changes.
Portable Chest X-Ray


The portable chest x-ray appears normal.
Urine Drug Screen


Benzoylecgonine: 350 ng/mL (<300)
Marijuana Metabolites (THC-COOH): 75 ng/mL (<50)
Negative for Amphetamines, Barbiturates, Benzodiazepines, Methadone, Opiates, and Tricyclic Antidepressants.

Select Relevant Management
ACE Inhibitors
Beta Blockers
IV Benzodiazepines