Massive troponin release and normal coronary arteries: Where does the truth lie?

A 55-year-old woman was referred to the emergency department of Padova University Hospital with acute chest pain extending up to the left shoulder. She had had fever a few days prior but no other symptoms. The patient, who was obese, smoked, and had a history of arterial hypertension, first received first-line amlodipine treatment that was interrupted because of poor compliance. No other traditional cardiovascular or thrombophilic risk factors were reported. One hour after the onset of chest pain, the patient called the emergency service; the electrocardiogram (ECG)3 recorded at home was unremarkable for acute ischemia (Fig. 1A). At the emergency department, after 80 min, the patient still complained of chest pain, the physical examination was negative, blood pressure was 220/110 mmHg, and heart rate was 78 beats/min. The results of the second ECG were the same as those of the first (Fig. 1B). Fig. 1. Electrocardiographic and imaging findings. First acute ECG recorded at home, unremarkable for acute ischemia (A); second ECG recorded at the emergency department (chest pain still present) not showing ST-segment elevation, but a more clear QS complex on V1–V3 (black rectangle) (B); coronary angiography showing the normal epicardial coronary artery, except the small caliber of the first septal branch of the anterior descending coronary artery (white circle on E) (C–E); T2-weighted sequence showing that the acute ischemic edema in the septum was detectable on the 4-chamber view (F); orthogonal views showing that on post-contrast CMR, the ischemic pattern of late gadolinium enhancement (white area) in the same region of the previously demonstrated edema confirmed the acute myocardial infarction (G–H); RCA, right coronary artery; LCX, left circumflex artery; LAD, left anterior descending artery. The initial cardiac troponin I (cTnI) concentration, obtained using a high-sensitivity assay (1), was markedly increased (57 ng/L) relative to the sex-dependent 99th percentile (16 ng/L). The …