Is the CP ischaemic?

A 72yo female presented with severe crushing chest pain following a particularly stressful experience. 

This is her ECG:

The TWI is both anterior and inferiolateral. Unusually there is an upright t wave in aVR and flattening of the t wave in aVL. There seems to be global ischaemia/ electrolyte abnormality or myocarditis. Given the hx of a stressful episode, the registrar performed an echo looking for takatsubo.

These are the echo findings:

Modified PLAx showing hyperkinetic basal segments and hypokinetic apex.

PSAx showing anterior and septal hypokinesis

Zoomed in view of LV from A4C

So the echo definitely shows features of takatsubo: apical ballooning + hypoekinesis and basal hyperkinesis. But given the patient's age and comorbidities, they were taken to  cath lab. They were found to have severe LAD stenosis. Her peak troponin was 1664.

She may still have had takatsubo with a coincidental finding of LAD stenosis. Her troponin is definitely not as high as you would expect with an AMI of that degree. Nevertheless, this just goes to show that it is always prudent to take these patients to cath lab. Takatsubo is a diagnosis of exclusion only. 

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