A woman in her early 70s presented to our emergency room 30 min after her husband expired with 8/10, substernal chest pain with concurrent diaphoresis and dyspnoea.
The patient's husband had an out-of-hospital cardiac arrest earlier that day and was brought to our emergency room and subsequently admitted to the coronary care unit.
He had recurrent ventricular fibrillation and could not be successfully resuscitated.
The patient's medical history included hypertension and hypothyroidism.
She denied having had a similar episode of pain.
She had regular appointments with her primary care physician.
Her medication included oral furosemide 20 mg and levothyroxine 100 µg, both once daily.
She denied allergies.
On presentation, the patient was afebrile, with a blood pressure of 105/55, heart rate of 93 bpm, respiratory rate of 20/min and an oxygen saturation of 98% on room air.
On physical examination, she was in significant distress due to pain.
Her skin was warm and moist, with minimal crackles in bilateral bases, regular rate and rhythm, 2/6 systolic murmur of the apex without radiation, no rubs, elevated jugular vein distention of 8 cm, strong peripheral pulses and no peripheral oedema.
The abdomen was soft, non-tender, non-distended, with bowel sounds, and the patient was alert and oriented without focal neurological deficits.
The complete blood count, basic metabolic panel and coagulation tests were within normal limits.
The cardiac enzymes were increased with a troponin I of 2.59 ng/mL (normal range 0.015–0.045 ng/mL), creatine phosphokinase of 84 U/L (normal range 26–192 U/L).
ECG on admission revealed normal sinus rhythm with 2–3 mm ST segment elevations in leads V2–V3 and Q waves in leads V1–V3, suggestive of anterior wall infarct (figure 2).
An echocardiogram revealed left ventricular ejection fraction of 30–35% with mild concentric left ventricular hypertrophy, akinesis of the apex and 2/3 of the inferoseptum and apical inferior-anterior wall segments, suggesting ischaemic damage at the left anterior descending artery distribution versus takotsubo cardiomyopathy (figures 3 and ​4).
The patient received aspirin 162 mg and prasugrel 60 mg, and was taken to the cardiac catheterisation laboratory.
The angiogram showed non-obstructive coronary artery disease with luminal irregularities (figures 5 and ​6).
The left ventriculography showed an ejection fraction of 35% with akinesis of apical wall and hyperkinesis of basal segments (figures 7 and 8).
The patient remained haemodynamically stable and was started on oral heart failure medications, including lisinopril 2.5 mg daily and metoprolol tartrate 12.5 mg two times a day.
Her pain and shortness of breath resolved and she was discharged home after 48 h of hospitalisation in stable condition.
A repeat echocardiogram 2 months later showed resolution of her cardiomyopathy and an ejection fraction of 65–70%, with normal left ventricular motion.