Palpitations and fatigue

A 65-year-old woman with past medical history of psoriasis, hypertension, hyperlipidaemia and smoking presented to the emergency department (ED) with a five-day history of intermittent palpitations that became persistent and increased in intensity the morning of presentation and were associated with fatigue. She denied any other symptoms. She was not taking any medications and was allergic to codeine. She denied use of alcohol or illicit drugs. Her family history was non-contributory. 

In the emergency department, vitals included a pulse of 107 beats per minute, blood pressure of 125/70 mmHg, temperature of 97.8° F, respiratory rate of 19 breaths per minute, and oxygen saturation of 100% on room air. Her physical examination was unremarkable. The presenting electrocardiogram revealed sinus tachycardia, ST elevation in aVR and diffuse ST-segment depression (Figure 1).

The patient received a 325mg aspirin tablet and her palpitations resolved. D-dimer and urine toxicology screen were negative. Cardiac enzymes were mildly elevated. After evaluation by the cardiology team, the patient was taken urgently to the catheterization laboratory for coronary arteriography. After right coronary artery (RCA) injections were completed, left coronary arteriography was conducted (Figure 2). The patient began experiencing chest pain, diaphoresis, and nausea.