For two weeks, a Spanish-speaking woman, 60, has experienced substernal chest pain and shortness of breath. The pain began while she was visiting family in Mexico. She was seen by a local physician, who prescribed a medication that helped but did not relieve the pain completely. She exhausted her supply of this medication shortly after returning from vacation, and her chest pain worsened.
The patient’s daughter transported her to your clinic, concerned that her mother may be having a heart attack. According to the daughter, who is interpreting, the pain is described as grade IV/X, intermittent, radiating to the back, and lasting for approximately 10 minutes before subsiding. It is exacerbated with activity, particularly climbing stairs, and resolves when the woman is at rest. She has been awakened by this pain on two occasions.
The patient denies fever, chills, nausea, vomiting, dizziness, or syncope. Medical history is remarkable for hypertension, diabetes, and asthma. She has worked most of her life as a farm worker and as a cook. She does not use alcohol and has a 20–pack-year history of tobacco use. The patient’s medications include aspirin, metformin, pravastatin, telmisartan, verapamil, and a salmeterol inhaler. She is allergic to penicillin.
Review of symptoms is remarkable for diarrhea that is resolving and headaches. Physical examination reveals a well-developed, obese woman who is comfortable, alert, and oriented. Her height is 5’3”; weight, 211 lb; blood pressure, 106/40 mm Hg; pulse, 80 beats/min; respiratory rate, 14 breaths/min; and temperature, 99.2°F.
The cardiovascular exam reveals a normal rate and rhythm with no murmurs, rubs, or extra heart sounds. There are no carotid bruits or peripheral edema. The lungs are remarkable for scattered expiratory wheezes in both bases, with the right greater than the left. The abdomen is large but soft with good bowel tones in all quadrants. There are no palpable bruits or organomegaly. The neurologic exam shows no gross neural deficits.
The serum glucose level is 148 mg/dL; hemoglobin, 10.6 g/dL; and troponin, 0.02 ng/mL. All other lab values are within normal limits. An ECG shows the following: a ventricular rate of 80 beats/min; PR interval, 168 ms; QRS duration, 130 ms; QT/QTc, 384/442 ms; P axis, 29°; R axis, –34°; and T axis, 96°. What is your interpretation of this ECG, and is there any evidence of ongoing ischemia?