Sharp pain under my left ribs since moving a sofa

The case

29-year-old man. Sharp pain under my left ribs since moving a sofa

A 29-year-old man presents to the emergency department with a sharp, left-sided chest-wall pain that began two days ago while twisting to move a sofa. The pain is worse on twisting and deep inspiration, and is reproduced by pressing on the left costochondral margin.

On arrival

BP: 128/76
RR: 14
SpO2: 99% on air
Temp: 36.7
Heart rate: 56

Stage 1 of 3

There is no history of exertional chest pain, syncope, palpitations, or family history of sudden cardiac death. He is fit and well and takes no regular medications. The triage ECG has printed "*** ACUTE MI ***" and the triage nurse asks whether to activate the catheterisation laboratory.

Tracing 1 of 2 for the quiz “Sharp pain under my left ribs since moving a sofa”. — 12-lead, 25 mm/s, 10 mm/mV Open this tracing in the studio

What is the most likely explanation for the ST changes on this ECG?

ABenign early repolarisation Correct answer Your answer
BAcute anterolateral STEMI Your answer
CAcute pericarditis Your answer
DLeft ventricular aneurysm Your answer

The ST elevation is concave and widespread, with J-point notching clearest in leads II, V4 and V5, and upright T waves that are proportionate to the QRS rather than hyperacute. There is no reciprocal ST depression in III or aVL, which would be expected with an anterolateral STEMI. The absence of PR-segment depression makes pericarditis much less likely. A left ventricular aneurysm produces persistent ST elevation but typically with pathological Q waves in the same territory.

What is the most useful next step?

AFind an old ECG for comparison, with serial ECGs and troponin Correct answer Your answer
BActivate the catheterisation laboratory Your answer
CGive aspirin and heparin and arrange urgent angiography Your answer
DDischarge now with simple analgesia Your answer

The morphology strongly favours early repolarisation, but the ST levels in V4 to V6 do meet the Fourth Universal Definition's millimetric thresholds. An old ECG showing the same pattern converts a plausible reading into a confident one and avoids both an unnecessary catheterisation laboratory activation and a premature discharge. Serial ECGs and troponin help exclude a superimposed acute injury. Discharging without any further investigation would be unsafe if this were a subtle occlusion.

Stage 2 of 3

The patient's electronic record contains an ECG from a pre-employment medical fourteen months earlier.

Tracing 2 of 2 for the quiz “Sharp pain under my left ribs since moving a sofa”. — 12-lead, 25 mm/s, 10 mm/mV Open this tracing in the studio

What does the comparison ECG establish?

AThe ST pattern is unchanged, confirming a stable baseline Correct answer Your answer
BThe ST elevation has worsened, suggesting acute injury Your answer
CNew T-wave inversion has developed since the earlier recording Your answer
DThe earlier ECG is normal, so the current changes are new Your answer

The ST morphology, the degree of elevation and the J-point notching on the comparison ECG are effectively identical to today's tracing. This confirms a longstanding baseline pattern rather than an acute change. The comparison is the single most valuable piece of information in this case: it turns an ECG that formally meets STEMI criteria into one that can be managed conservatively with serial troponin.

Stage 3 of 3

High-sensitivity troponin T is less than 5 ng/L at presentation and again at one hour. A repeat ECG at one hour is unchanged.

Bloods

hs-troponin T (0 h): < 5 ng/L
hs-troponin T (1 h): < 5 ng/L

What is the most appropriate disposition?

ADischarge with analgesia and advise him to keep a copy of this ECG Correct answer Your answer
BAdmit for cardiac monitoring overnight Your answer
CArrange outpatient cardiac MRI within one week Your answer
DRefer for electrophysiology assessment Your answer

With a stable baseline ECG, undetectable serial troponin, a reproducible musculoskeletal cause for the pain and no red-flag features, discharge is appropriate. Advising the patient to keep a copy of this ECG is a practical step that will help any future clinician avoid the same diagnostic uncertainty. Admission, cardiac MRI and electrophysiology assessment are not warranted in the absence of dynamic ECG changes, a troponin rise, syncope, or a family history of sudden cardiac death.

Which feature, if present, would have raised concern about this early repolarisation pattern?

AInferolateral J waves with a horizontal or descending ST segment Correct answer Your answer
BST elevation exceeding 2 mm in any single lead Your answer
CSinus bradycardia below 60 beats per minute Your answer
DProminent precordial R-wave voltage Your answer

An inferolateral J-wave pattern with a horizontal or descending ST segment has been associated with an increased risk of ventricular fibrillation, particularly when accompanied by unexplained syncope or a family history of sudden cardiac death. This patient's pattern is anterolateral with concave, upsloping ST segments, which carries no such prognostic concern. The absolute height of ST elevation, sinus bradycardia and tall R waves are not features that distinguish a worrying early repolarisation pattern from a benign one.

Diagnosis

Benign early repolarisation

This ECG shows benign early repolarisation: widespread concave ST elevation with J-point notching, upright T waves in proportion to the QRS, and no reciprocal ST depression outside aVR. The ST levels in V4 to V6 formally meet the Fourth Universal Definition's millimetric thresholds for ST-elevation myocardial infarction, which leads to automated flagging by the ECG machine.

The comparison ECG from fourteen months earlier is effectively identical, confirming a stable baseline rather than an acute change. The high-sensitivity troponin is undetectable at both timepoints. Together these make acute myocardial injury vanishingly unlikely. This is a young man with a reproducible musculoskeletal pain and a normal variant ECG. He should keep a copy of his ECG to avoid diagnostic traps in the future. The pattern here is anterolateral and concave, which carries no prognostic concern. The features that would have warranted further investigation are an inferolateral J-wave pattern with a horizontal or descending ST segment, unexplained syncope, or a family history of sudden cardiac death.

References

Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019;40(3):237-269.
Macfarlane PW, Antzelevitch C, Haissaguerre M, et al. The early repolarization pattern: a consensus paper. J Am Coll Cardiol. 2015;66(4):470-477.
Haïssaguerre M, Derval N, Sacher F, et al. Sudden cardiac arrest associated with early repolarization. N Engl J Med. 2008;358(19):2016-2023.

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Discussion

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