A 73-year-old woman with retrosternal pain but no obstructive coronary artery lesion on coronary angiography

Abstract

A 73-year-old woman sought medical assistance at another hospital complaining that she had experienced retrosternal pain that irradiated to the mandible on the day before. She also reported sweating, nausea, vomiting, and dizziness. Acute ischemic heart syndrome was then diagnosed. The laboratory assessment showed the following results: hemoglobin, 12.3g/dL; hematocrit, 36.3%; leukocytes, 11,800/mm 3 (neutrophils, 83%; eosinophils, 4%; lymphocytes, 11%; monocytes, 2%); platelets, 179,000/ mm3; and the following serum values: creatinine, 0.9mg/dL; urea, 68mg/dL; sodium, 140mEq/L; potassium, 4.4mEq/L; total CK, 132 U/L (reference range values: 25 to 170 U/L); MB fraction of creatine kinase, 13 U/L; aspartate aminotransferase (AST), 16 U/L; lactate dehydrogenase 355 U/L (reference range values: 180 to 460 U/L). As part of the medical treatment, a coronary angiography was indicated.On the following day, she had the same symptoms again, and the pain lasted approximately 3 hours. She then sought medical treatment at InCor. She denied other symptoms, arterial hypertension, diabetes mellitus, or dyslipidemia.On physical examination the patient was in regular condition, eupneic, and pale. Her pulse frequency was 76bpm, her blood pressure was 130/60mmHg, and the pulses were symmetrical with normal amplitudes in the limbs. The lungs, heart, and abdomen showed no abnormalities on physical examination.The electrocardiogram showed atrioventricular dissociation with a variation in the shape of the QRS complex, a heart rate of 72bpm, QRS duration of 80 msec, and QRS axis + 30º backwards. The ST segment and the T waves showed plus-minus T waves from V 4 to V 6 ( fig. 1). The chest X-ray (June 7) raised the suspicion of mediastinal enlargement.Serum levels of the MB fraction of creatine kinase 3, 11, 16, and 24 hours after the pain started were, respectively, 11, 7, 4, and 11 U/L. The remaining results of the laboratory assessment are shown in table I.The transthoracic echocardiogram showed a moderate concentric hypertrophy of the left ventricle and normal systolic function (diastolic diameter, 46mm; systolic diameter,