Chest Pain and T-Wave Inversions in a 56-Year-Old Man

A 56-year-old man presented to cardiology clinic with daily episodes of chest heaviness and discomfort.He underwent an echocardiogram, which showed no evidence of structural heart disease.An exercise nuclear stress test showed average functional capacity and normal perfusion.Because of his daily symptoms, the patient wore a 24hour Holter monitor (Figure 1A), which showed multiple episodes of T-wave inversions (Figure 1B), inconsistently associated with his symptoms of chest tightness.Because of these symptoms, he underwent coronary angiography, which showed minimal coronary artery disease.What is the mechanism of the T-wave inversions seen on Holter?Please turn the page to read the diagnosis. Chest Pain and T-Wave Inversions in a 56-Year-Old Man