Jazz Musician Hangs by a String

65-year-old musician with type 1 diabetes mellitus was referred to the cardiology department for shoulder pain, which he had experienced while pushing his double bass on the way to a performance. The patient, who exercised regularly, had not had chest pain, shortness of breath, or palpitations. He had a 25-pack-year history of tobacco use but had quit 14 years earlier. He had no family history of coronary artery disease. Results of electrocardiography and echocardiography showed nothing of note. His high-density-lipoprotein cholesterol level was 83 mg/dL, and low-density-lipoprotein cholesterol was 87 mg/dL. Carotid duplex ultrasonogra phy revealed heterogeneous fibrocalcific plaques bilaterally but was otherwise normal. During nuclear stress testing, the patient exercised for 9 minutes with recurrence of discomfort. At peak exercise, there were 2-mm horizontal ST-segment depressions in the inferior and lateral leads (Fig. 1). Single-photon-emission computed tomographic imaging showed large, severe, primarily reversible mid-distal, anteroseptal, anterior, and apical defects with a large, mild lateral defect (Fig. 2). Left heart angiography revealed occlusion of the left main coronary artery and an extensive network of collateral vessels (Fig. 3), 70% mid-right coronary artery stenosis, and a left ventricular ejection fraction of 0.60. The patient underwent coronary artery bypass grafting, tolerated it well, and is moving on to his next performance.

Fig. 1 Stress test electrocardiography at peak exercise shows 2-mm horizontal ST-segment depressions in leads II, III, aVF, V₄, V₅, and V₆.

Fig. 2 Single-photon-emission computed tomographic imaging shows a large, severe-intensity, primarily reversible perfusion defect involving the left ventricular mid-distal, anteroseptal, anterior, and apical walls, as well as a large, mild lateral defect.

Fig. 3 Coronary angiograms show A) the left main coronary artery occlusion (left anterior oblique view) and B) the mid-right coronary artery obstructive lesion (left anterior oblique cranial view). Note the extensive network of collateral vessels reaching the left main coronary artery.