A mimicry of an acute coronary syndrome.

Background: A 79-year-old woman was out in the garden having lunch on a hot summer's day. She developed stabbing chest pains more severe on her left side, associated with radiation down her left arm. Severity was 7 out of 10. There was no relief of pain with glyceryl trinitrate spray. Risk factors for ischaemic heart disease include hyperlipidaemia, being an ex-smoker 40 years ago, no history of diabetes or hypertension. There was a family history of her father having a myocardial infarction at the age of 54. ECG revealed widespread deep symmetrical T-wave inversion in the chest leads and lateral limb leads.

Investigations: The patient's serum creatine kinase level was 180 IU/l (normaL range 30-135), troponin I level was 6.56 g/l (normal range 0-0.10), D-dimer was negative and random serum cholesterol level was 5.3 mmol/l (3.8-5.2). Significant coronary stenoses were excluded. A left ventriculogram revealed a hyperkinetic base and a dyskinetic apical region of the left ventricle. Echocardiography showed normal valves, basal septal hypertrophy and a dilated akinetic apex, with the region of akinesia spanning more than the arterial territory.

Diagnosis: Takotsubo cardiomyopathy.

Management: Treatment with aspirin, ACE inhibitor, beta blocker and a statin.