An atypical presentation of acute coronary syndrome

A 53-year-old woman, with a body mass index of 25.6 kg/m2, and a past medical history consisting of type 2 diabetes mellitus diagnosed 10 years earlier, hypertension, hyperlipidemia and remote smoking presented to the emergency department complaining of chest heaviness, shortness of breath and general myalgia. Her heart rate was 114 beats per minute, blood pressure was 190/100 mmHg, and she was quite anxious. The initial electrocardiogram (ECG) (Figure 1) showed ST-elevation in AVR and diffuse ST depression in anterolateral and inferior leads. First Troponin-T Level measurement was 39 ng/L and the next one elevated to 67 ng/L (normal ≤14 ng/L). The initial diagnosis was acute myocardial infarction and therefore, she was transferred to our medical center for urgent coronary angiogram. Transradial coronary angiography revealed non-obstructive coronary artery disease and left ventriculography showed preserved ejection fraction with antero-basal hypokinesis