Images in Cardiovascular Medicine Uncommon Cause of ST Elevation

epigastric pain that did not radiate. He had 6 episodes of emesis followed by retching. The character of the pain was different from past anginal symptoms. At his local emergency department, a chest roentgenogram revealed air presumably within a large intrathoracic hiatal hernia (Figure 1). Com-puted tomography was notable for the stomach being almost entirely intrathoracic and distended with an organo-axial volvus configuration (Figure 2). A nasogastric tube was inserted, and he was transferred to our institution. His medical history included hiatal hernia, hypertension, dyslip-idemia, diabetes mellitus, and chronic kidney disease. He had undergone coronary artery bypass grafting 26 years previ-ously with vein grafts to his left anterior descending artery and right coronary artery. Ten years ago, he had redo surgery with a left internal mammary artery to the left anterior descending artery. His medications included aspirin, b-blocker, angiotensin receptor blocker, statin, and nitrates. He was afebrile; his pulse was 73 bpm and blood pressure was 169/87 mm Hg. Chest examination revealed a significant systolic upper sternal lift with normal chest auscultation. His abdomen was not tender. He had normal leukocyte count, creatinine of 1.5 mg/dL (normal values, 0.8 to 1.3 mg/dL),