Abstract 2010: A 54 year old Woman Presents with Angina, Syncope and a Devastating Clinical Course
A 54 year-old woman presented with a 2 week history of exertional chest discomfort and recent syncope. She described the discomfort as substernal chest pressure often accompanied by dyspnea. She had recently had a negative adenosine stress test. Her history was notable for inflammatory bowel disease and the lack of conventional coronary risk factors. Her exam was notable for the lack of tachycardia or hypertension, and prominence of the P2. Her evaluation included an EKG with downsloping ST depressions and elevated serum troponin I. A clinical diagnosis of unstable angina was made and she was treated with antiplatelet and anticoagulant regimens. A cardiac catheterization was arranged for the following morning since she remained free of rest symptoms. The following morning, she had hematemesis followed by cardiac arrest before the scheduled catheterization. At autopsy, large amounts of retained blood were seen in the gastrointestinal track and a circumferential subendocardial myocardial infarction was present. Microscopic evaluation revealed extensive amyloid deposition throughout her heart and gastrointestinal system. This case report illustrates that rare disorders such as amyloidosis may present with common clinical syndromes such as unstable angina with devastating consequences. It also emphasizes that electrocardiographic changes and elevated biomarkers of necrosis are not universally synonymous with thrombosis mediated myocardial infarction. Although heart failure is the predominant presenting clinical picture of cardiac amyloidosis, amyloid angiopathy may produce angina indistinguishable from coronary atherosclerosis. Amyloid is also directly toxic to myocytes and may cause myocyte necrosis. The systemic nature of this disorder is also important to consider.