31-Year-Old Female With Acute Chest Pain

A 31-year-old Caucasian female with history of hyperlipidemia who is an active smoker and is taking oral contraceptive pills for the last 10 years presented to the emergency department with constant substernal chest pain that started while jogging 3 hours prior to presentation. The chest pain was associated with numbness and tingling in the left arm; it was not related to position. She denied recent cough, fever, calf pain or swelling, or illicit drug use. Of note, the patient travels frequently to the West Coast for work. She has a strong family history of premature coronary artery disease (her brother had a myocardial infarction [MI] at age 40, and her mother had a coronary artery bypass graft at age 50).

Her physical exam was unremarkable with normal vital signs and no significant cardiac findings. Her initial electrocardiogram (ECG) showed normal sinus rhythm at 61bpm with nonspecific ST-T changes in the inferior leads and V3-V4. Initial troponin T and creatine kinase-myocardial band (CK-MB) were negative, and her white blood cell count was 20. Computed tomography angiogram of thoracic aorta was negative for dissection. The patient was given famotidine, an antacid, and acetaminophen, and her pain subsided. A repeat set of cardiac enzymes were positive, with troponin T of 1.03 and CK-MB of 54, and dynamic ST-T changes on a repeat ECG were noted in the inferior leads. The patient was admitted to the cardiac care unit for non-ST-segment elevation MI (NSTEMI) and started on aspirin, clopidogrel, low molecular weight heparin, rosuvastatin, and metoprolol. Transthoracic echocardiogram revealed a left ventricular ejection fraction of 60-65% and no regional wall motion abnormalities. The patient was taken to the cardiac catheterization laboratory with the results noted below.

Video 1

Video 2

Video 3

Video 4

What is the most likely diagnosis?

Show Answer