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Archives of Medical Science
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vol. 14
Letter to the Editor

Myocarditis presenting as variant angina: a rare presentation

Amole O. Ojo, Chhaya A. Gupta, Anthon Fuisz, Zeeshan Solangi, Prakash Harikrishnan, Howard A. Cooper, Julio A. Panza, Wilbert S. Aronow

Arch Med Sci 2018; 14, 5: 1175–1179
Online publish date: 2017/07/17
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Myocarditis is inflammation of the myocardium caused by an infectious or autoimmune process. Myocarditis may present with a broad range of symptoms, ranging from mild shortness of breath or chest pain that resolves without specific therapy to cardiogenic shock and death [1]. Myocarditis presents very rarely as variant angina pectoris due to coronary artery spasm.
A 45-year-old man with no significant past medical history other than a recent urinary tract infection presented to the emergency department (ED) with substernal chest pain. The chest pain was described as a substernal pressure which lasted for 45 min and was associated with a feeling of doom. There were no known aggravating or alleviating factors. He had no known cardiovascular risk factors and he denied recent use of recreational drugs. His system review was positive for dysuria and diarrhea. The blood pressure was 123/79 mm Hg, the heart rate was 76 bpm, and the respiratory rate was 14/min. The patient was afebrile. The oxygen saturation was 99% on room air. Physical examination including cardiovascular examination was normal.
The electrocardiogram (ECG) showed sinus rhythm with ST-segment elevation in the inferior and anterolateral leads (Figure 1). A preliminary diagnosis of ST-segment elevation myocardial infarction (STEMI) was made, and the patient was taken immediately to the cardiac catheterization laboratory. Coronary angiography showed normal coronary arteries (Figures 2 A, B). The chest pain completely resolved and the patient was admitted to the coronary care unit. Transthoracic echocardiography demonstrated a normal left ventricular ejection fraction (60%) and no regional wall motion abnormalities. A repeat ECG obtained one hour after coronary angiography showed near complete resolution of the ST-segment elevation (Figure 3).
Seven hours later, the patient developed another episode of chest pain. The ECG then showed increased ST-segment elevation in the inferior and anterolateral leads (Figure 4). The chest pain and ECG changes quickly resolved after treatment with sublingual nitroglycerin (Figure 5). A diagnosis of coronary artery spasm was made.
The urine drug screen was negative. Abnormal laboratory findings included a white blood cell count of 24,800/mm3, a cardiac troponin I which peaked at 21.01 µg/ml (cut off value in our laboratory 0.02 µg/ml), and a creatine kinase MB fraction which peaked at 125.1 IU/l (cut off in our laboratory value 6.6 IU/l)....

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