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

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