Abstract 13820: Four Revelations on the Table of Truth: A Confounding Case of ST Elevation

Background: We present a case of a patient with new onset ST elevation on EKG, found to have multiple pathologies on emergent cardiac catheterization. Case: A 81 yo woman with no prior cardiac problems; with syncope 3 days ago, came to the emergency department with worsening left-sided chest pain, that started a few hours earlier. Vitals were within normal limits. She was noted to have left facial ecchymosis, from the fall. She had an otherwise normal physical exam. Her EKG on presentation showed ST elevation in anterior leads with deep T wave inversions. She was planned for emergent cardiac catheterization following noncontrast head CT that showed no intracranial bleed. In the lab, she had no evidence of obstructive epicardial coronary artery disease. However, we noted abnormally slow filling of coronaries (suggestive of microvascular dysfunction) and evidence of a myocardial bridge in the mid-segment of the left anterior descending artery. Since neither of these would explain her acute presentation, a left ventriculogram was performed that showed apical ballooning suggestive of Takotsubo cardiomyopathy and filling defect consistent with thrombus. MRI brain showed acute ischemic stroke involving the right occipital lobe which was likely the physical stressor in her case. Discussion: Takotsubo cardiomyopathy is frequently associated with ST elevations and T wave inversions on EKG. It is hypothesized that microvascular dysfunction may be more common in Takotsubo cardiomyopathy and may explain its increased incidence among post-menopausal women and the correlation with emotional and physical stressors. Myocardial bridge of the left anterior descending artery has been associated with stress cardiomyopathy in up to 76% of cases. Conclusion: This is a rare case of stress cardiomyopathy that presented with both evidence of microvascular dysfunction and prominent myocardial bridge, with all three conditions being diagnosed in the cardiac catheterization lab.