A 70 year old woman with chest pain after a stressful eventBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5583 (Published 23 September 2013) Cite this as: BMJ 2013;347:f5583
- Nikolaos Dagres, assistant professor cardiologist,
- Andreas Triantafyllis, resident in cardiology,
- Maria Anastasiou-Nana, professor cardiologist
- 1Second Cardiology Department, University of Athens, Attikon University Hospital, Haidari 12462, Athens, Greece
- Correspondence to: N Dagres
A 70 year old woman was referred to the emergency department from a remote healthcare facility for chest pain of sudden onset after seeing her garden on fire. The pain, which lasted for 15-20 minutes, was severe, sharp, radiating to the neck, and accompanied by nausea. Her medical history included dyslipidaemia and she had a family history of coronary artery disease.
She arrived at the emergency department about 24 hours after the onset of symptoms. She was haemodynamically stable, with a blood pressure of 140/60 mm Hg, a heart rate of 75 beats/min in sinus rhythm, and an oxygen saturation on room air of 99%. Physical examination and body temperature were normal. The 12 lead resting electrocardiogram showed negative T waves in leads I, II, aVL, and the precordial leads V2 to V6 (fig 1⇓). Chest radiography including the cardiothoracic ratio was normal. Initial blood tests showed mildly raised troponin concentrations (157 pg/mL; normal value <14;), whereas other routine test results, including inflammatory markers, were normal (C reactive protein 4.2 mg/L, white blood cell count 8.49×109).
The echocardiogram showed a moderately impaired left ventricular ejection fraction (40%) with segmental wall motion abnormalities: she had apical and midventricular hypokinesia of the left ventricle, whereas the basal segments were hyperkinetic.
She underwent cardiac catheterisation with the working diagnosis of a non-ST elevation myocardial infarction. Coronary angiography showed unobstructed coronary arteries, whereas left ventriculography showed apical akinesia (fig 2⇓).
1 What is the diagnosis?
2 Which …
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