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anticoagulants were withdrawn, and she was put on Bisoprolol 1.25 mg OD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.