Vasospastic angina preceding diagnosis of arrhythmogenic cardiomyopathy in a young athlete

Figures

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  Figure 1. Chronological changes of the 12-lead electrocardiogram (ECG) and cardiac enzymes. A: Changes of the 12-lead ECG. Note that notched QRS waves were observed in the precordial leads on admission and on days 3 and 4 of admission, which normalized during further observations. Prolonged QT intervals were not observed throughout the clinical course. B: Changes of the cardiac enzymes. The green line depicts creatine kinase (CK); red line, Troponin I (TnI); and blue line, B-natriuretic peptide (BNP). Note that the BNP levels remain relatively low during acute phase.

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  Figure 2. Cardiac catheterization and magnetic resonance imaging. A: Ventriculograms. An apical left ventricular aneurysm was seen by the left ventriculogram (LVG) (white arrow). The right ventriculogram (RVG) showed a dilated chamber, but the ejection fraction was preserved (end-diastolic volume index: 172 mL/m2, ejection fraction 50%). The right ventricular outflow tract was not clearly dilated. B: Results of the acetylcholine provocation test. The left panels show left coronary arteriograms at baseline, after injection of 20 μg acetylcholine, after injection of 50 μg acetylcholine, and after injection of isosorbide dinitrate (ISDN). Note that diffuse vasoconstriction and focal semi-occlusion of #10 (yellow square in the high magnification panel) were observed. The right panels show the precordial leads of the electrocardiogram corresponding to each condition, indicating ST-T and T-wave morphological change in V4-V6. C: Cardiac magnetic resonance imaging with gadolinium-DTPA 2 months after onset showed delayed enhancement (white arrow) in the apex of the left ventricle (left) and free wall of the right ventricle (right).

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  Figure 3. Two-year clinical courses after the first chest pain attack. A: The chronological changes of BNP and troponin I levels after discharge. Red bars depict exercise restriction; green bar, light exercise. Note that the plasma BNP levels repeatedly increased with light exercising. B: The cardiac magnetic resonance image 2 years after onset shows marked dilatation of right ventricular outflow tract, which was not apparent at the onset (white arrows). Delayed enhancement with gadolinium contrast was observed (yellow arrows). C: A 12-lead electrocardiogram 2 years after onset (left panel). Premature ventricular contractions with superior axis were observed (right panel). D: An echocardiogram 2 years after onset shows the left ventricular aneurysm observed at the onset (∗).