A 32 year old man has presented after developing left sided chest pain whilst shoveling in the garden. He feels sweaty and dizzy. He is a FIFO worker with no medical history.

His observations are: HR 110, BP 160/110, RR 24, Sats 95% air, T36.4

His EGC is as below:

Interpretation:

• Rate: 120
• Rhythm: sinus rhythm
• Axis: RAD +120
• Morphology:
  • P waves – biphasic
  • QRS – delta pattern, septal Q waves,
  • T waves – biphasic, notable in V5-6
• Intervals: QTc 450

Differential Diagnosis:

• Acute coronary syndrome (including vasospastic given age)
• PE
• Aortic Dissection
• Myocarditis
• Cardiomyopathy

Clinical Closure:

• Admitted to regular meth use
• Trop 350 –> 3450
• CXR: prominence of bronchovascular markings and subtle airspace shadowing constant with early signs of fluid overload
• CTPA: no PE or Aortic dissection – again features of APO
• Echo: Diffuse hypokinesis of LV, EF 22%, Moderately dilated RA
• Coronary angio: no abnormalities
• Treated as non ischaemic (METH induced) cardiomyopathy, admitted under cardiologists for 3 days.
• Related to ECG
  • Dilated RA = p pulmonale (LAA)
  • Poorly functioning LV = RAD, Pseudo WPW likely related to evolving BBB, Q waves in antr leads
  • Meth use (other cause not identified) prolonged QTc