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JAMA Cardiology Clinical Challenge
June 30, 2021

A Woman in Her 70s With Hypotension, Diffuse ST-Elevation, Murmurs, and an Intracardiac Mass

Author Affiliations
  • 1Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
JAMA Cardiol. 2021;6(10):1217-1218. doi:10.1001/jamacardio.2021.2012

A previously healthy woman in her early 70s was referred to our emergency department with exertional dyspnea. She reported recent physical and emotional stress from work and dizziness 2 days prior to presentation. She denied fever or palpitations. Her blood pressure was 84/59 mm Hg. A harmonic, musical systolic murmur was heard at the left third intercostal space. An electrocardiogram (ECG; Figure 1A) showed diffuse ST-segment elevation, most prominently in the anterior precordial leads. Laboratory evaluation revealed elevated levels of troponin (1.33 ng/mL; normal range: ≤0.016 ng/mL [to convert to micrograms per liter, multiply by 1.0]), brain natriuretic peptide (376.5 pg/mL; normal range: ≤18.4 pg/mL [to convert to nanograms per liter, multiply by 1.0]), creatinine phosphokinase (96 U/L; normal range: 41-153 U/L), and D-dimer (0.68 μg/mL; normal range: ≤1.00 μg/mL [to convert to nanomoles per liter, multiply by 5.476]). Echocardiography showed left ventricular (LV) wall-motion abnormalities involving the mid and apical segments and an LV apical mass with protruding features. Noncontrast computed tomography confirmed the high-density LV mass (Figure 1B). Coronary angiography revealed mild to moderate coronary atherosclerosis without obstructive coronary artery disease.

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