Differential diagnosis, investigations and treatment
A presenting Electrocardiogram (ECG) was obtained (Fig.1), which showed global ST-segment depressions, most prominent in Leads II, aVF, and V2-V6, along with T-wave inversions in V3-V6. High-sensitivity Troponin levels were recorded as 1.639 ng/dL (normal < 0.063 ng/dL). The patient was immediately treated in accordance with the Acute Coronary Syndrome (ACS) protocol under the impression of an ischemic attack.
After the initial stabilization of the patient, Echocardiography was done, which elucidated inferior and basal segment hypokinesia and an Ejection Fraction of 50% (Fig. 2), with a Global Longitudinal Score (GLS) of -14 (Fig. 3). The typical presentation of ACS, yet the unremarkable history and unsupportive biodata of the patient presented a diagnostic dilemma for the physicians, who suspected a congenital anomalous coronary artery disease which might have been responsible for the development of ischemia in a young female. In lieu of this differential, a cardiac angiography was planned, which yielded an unremarkable anatomical variation in the patient and also excluded any obstructive lesion (Fig. 4).
Next, a cardiac MRI reiterated the echo findings, with normal Late Gadolinium Enhancement (LGE) and mild edema noted at the inferior wall segment. Also, there was no scar present (Fig. 5). The patient was observed in the Cardiac Care Unit for a day, after which she was stepped down. Subsequently, the diagnosis of ischemic attack was excluded, anticoagulants were withdrawn, and she was put on Bisoprolol 1.25 mg OD during the rest of her hospital course. Her sequential Troponin levels showed a steady decline toward the therapeutic range, from 0.211 ng/dL to 0.048 ng/dL. During the hospital stay of 3 days, she was completely symptom-free and was discharged on tablet Bisoprolol 2.5 mg OD.