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Cardiovascular Images
January 23, 2019

A Woman in Her 40s With Non–ST-Elevation Myocardial Infarction

Author Affiliations
  • 1The Heart and Vascular Institute, Department of Internal Medicine, University of Texas Health Science Center, Houston
  • 2The Heart and Vascular Institute, Division of Cardiovascular Medicine, University of Texas Health Science Center, Houston
JAMA Cardiol. 2019;4(2):186. doi:10.1001/jamacardio.2018.4621

A woman in her 40s with an unremarkable medical history presented to the emergency department for midsternal, pressurelike chest pain. Although she was stable on room air (blood pressure, 140/70 mm Hg; heart rate, 90 beats per minute), the pain persisted despite nitroglycerin administration. Workup results revealed elevated troponin I levels that rose from 0.38 ng/mL (to convert to micrograms per liter, multiply by 1) to 51.00 ng/mL, with ST-segment depression at the inferior leads. Transthoracic echocardiogram results indicated normal cardiac function and structure. Coronary angiogram results ruled out obstructive atherosclerosis but showed significant hypoperfusion at the mid–left anterior descending artery, pronounced during systole and early diastole (Figure; Video). These findings suggested an intramyocardial bridge that was causing myocardial ischemia. Varying from clinical silence to sudden cardiac death, the presentation depends on bridge location, length, and depth; the latter is classified as either superficial or deep (>10 mm).1,2 Nitrates may exacerbate symptoms and are contraindicated.3,4 The patient responded well and was discharged with metoprolol, 25 mg twice daily, aspirin, 81 mg daily, and atorvastatin, 40 mg daily. At 2-month follow-up, she reported no recurrence.

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