case_images: PMC10106591_01
case_images: Emergency electrocardiogram (ECG) was performed at rest showed normal sinus rhythm with no significant ST-T changes in all leads (A); Echocardiography in ER indicated a mildly thickened ventricular septum and left ventricular posterior wall, mild tricuspid regurgitation and a slightly reduced left ventricular ejection fraction (LVEF 50%) (B and C).
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case_images: PMC10106591_01_fcvm-10-1134658-g001.jpg
case_images: F1
case_images: ER showed a mildly thickened ventricular septum and left ventricular posterior wall, mild tricuspid regurgitation, and slightly reduced left ventricular ejection fraction (LVEF 50%, normal range: 55%-75%) (Figures 1B,C). ER laboratory tests indicated normal troponin I of 0.016 ng/mL (normal range, 0-0.04 ng/mL), creatine kinase MB isoenzyme of 0.7 ng/mL (normal range, 0-5.0 ng/mL), and myoglobin of 14.1 ng/mL (normal range, 0-70.0 ng/mL) levels.
case_images: Twelve minutes after hospitalization, the chest pain recurred, and monitoring ECG revealed ST-T segments elevation in lead II and complete AV-B with HR 41 bpm accompanied by hypotension (BP 96/51 mmHg) (A,B). Five milligrams of diltiazem was administered intravenously with prompt relief of chest pain, and complete AV-B was converted back to sinus rhythm (C). Coronary angiography on day 2 revealed nonobstructive coronary arteries in the LAD, (D), LCX, or (E) RCA (F). ECG, electrocardiogram; AV-B, atrioventricular block; HR, heart rate; LAD, left anterior descending artery; LCS, left circumflex branch; RCA, right coronary artery.
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case_images: F2
case_images: AV-B with HR at 41 beats/min accompanied by hypotension (BP at 96/51 mmHg) (Figures 2A,B). According to the characteristics of the patient's chest pain, ECG (near normal when chest pain was relieved), and biomarker (normal troponin I) obtained in ER, the diagnosis of CAS was highly suspected. With a possible diagnosis of CAS, 5 mg of diltiazem was administered intravenously with prompt relief of chest pain, and complete AV-B was converted back to sinus rhythm (HR at 59 beats/min) (Figure 2C).
case_images: Repeated ECG revealed normal heart rate without ST-T changes after diltiazem treatment. ECG, electrocardiogram.
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case_images: F3
case_images: Repeated troponin (0.031 ng/mL) and ECG were normal (Figure 3).