A 57-year-old female patient with a history of hypercholesterolemia and occult accessory pathway ablation 5 years prior.
Likewise, three months ago, after a discussion, she was admitted to an ICU of another hospital because she had an episode of chest pain with ST-segment elevation in precordial and inferior leads of the electrocardiogram (ECG 4.5 ng/mL).
Emergency transthoracic echocardiography (TTE) showed extensive apical akinesia along with an intraventricular gradient higher than 90 mmHg and moderate-severe mitral regurgitation.
The patient was treated with beta-blockers and fibrinolysis was discouraged because she had more than 12 hours of evolution.
After this, the patient remained asymptomatic.
After three days of evolution, the ECG showed a subepicardial ischemia in the extensive conserved LV. A coronary angiography was requested, where the coronary arteries showed no angiographic lesions, the left ventricle (LV) was not segmental hypertrophy.
She was discharged with beta-blockers and lipid lowering medication.
The subsequent evolution was favorable, and two months after admission beta-blocker treatment was withdrawn in the cardiology consultation.
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One month after this consultation, the patient again suffered, after another discussion, an episode of chest pain similar to that of a few months ago, although of lower intensity, reason why she was admitted to the ICU of our hospital.
The ECG was normal and there was no enzyme elevation.
On physical examination, the patient presented with a narrow gradient of the left ventricle and a narrow pansystolic murmur irradiated to the axilla and to the carotids. An urgent TTE was performed, showing a prominent LV without systolic hypertrophy.
The global and segmental contractility was preserved and the left atrium was small.
The suspicion of LVOT obstruction and taking into account the antecedents described, beta-blocker treatment was initiated early and at high doses, after which the patient became asymptomatic.
After 12 hours a second TTE showed the disappearance of both a significant gradient at the level of LVOT (maximum gradient 16 mmHg) and MAS, and the permanence of an MI II/IV.
