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A 70 year old woman with chest pain after a stressful event

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5583 (Published 23 September 2013) Cite this as: BMJ 2013;347:f5583
  1. Nikolaos Dagres, assistant professor cardiologist,
  2. Andreas Triantafyllis, resident in cardiology,
  3. Maria Anastasiou-Nana, professor cardiologist
  1. 1Second Cardiology Department, University of Athens, Attikon University Hospital, Haidari 12462, Athens, Greece
  1. Correspondence to: N Dagres nikolaosdagres{at}yahoo.de

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).

Fig 1 Resting 12 lead electrocardiogram at admission about 24 hours after symptom onset showing repolarisation abnormalities and negative T waves in several leads

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).

Fig 2 Left ventriculography in right anterior oblique 30° projection at diastole (A) and systole (B). Apical ballooning is evident, with apical akinesia and hypercontractility of the basal segments

Questions

  • 1 What is the diagnosis?

  • 2 Which …

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