A Shocking Development in a Young Male Athlete With Chest Pain

Information about a real patient is presented in stages (boldface type) to an expert clinician (Dr Deepak L. Bhatt), who responds to the information, sharing his reasoning with the reader (regular type). A discussion by the authors follows. P atient presentation: A 32-year-old male endurance athlete with no significant past history was admitted after experiencing multiple episodes of chest tightness while training for a triathlon. Occasionally, when running up hills, he noted substernal chest pressure that radiated to his left arm and was associated with severe shortness of breath. His past medical history includes seasonal allergic rhinitis and childhood asthma. He takes cetirizine/pseudoephedrine occasionally, but has not taken it recently, and denies taking any other medication or over-the-counter supplement. He admits to occasional binge drinking of 6 to 10 beers once or twice a month. He quit smoking 2 years ago but previously smoked a pack a week for 5 years. He also endorsed a remote history of cocaine use and recent marijuana and energy drink (1–2 small cans; 80 mg of caffeine per 8.4-oz can) use. His family history is only notable for a maternal grandmother who had a myocardial infarction in her 60s and a sister diagnosed with an atrial tachycardia. There is no history of premature coronary artery disease, heart failure, or sudden death. His biological parents and brother are alive and well. Dr Bhatt: At this point, the differential diagnosis for chest pain in a young, otherwise healthy patient is broad. Certainly, the exertional component of his symptoms is concerning and raises the possibility of premature coronary artery disease, although the family history obtained does not suggest a strong predisposition for atherosclerosis. Coronary artery vasospasm would be another possibility, and he has several potential triggers, including alcohol, pseudoephedrine, caffeine, and marijuana use. Vasospasm can occur with …