Worsening chest pain and dyspnoea on exertion in an older woman

A woman in her 70s presented with a one hour history of chest pain and dyspnoea while climbing stairs. She was hypertensive but had no cardiac disease or family history of sudden cardiac death at a young age. On presentation her blood pressure was 106/84 mm Hg, her pulse rate was irregularly irregular, and the intensity of the first heart sound was variable. On auscultation, a grade 3/6 systolic ejection murmur heard best at the lower left sternal border was detected.

Laboratory tests were performed. Troponin I was 0.06 μg/L (reference range 0.01-0.02 μg/L) and N-terminal pro-B-type natriuretic peptide was 1900 pmol/L (reference range 300-900 pmol/L). Figure 1 shows the electrocardiogram obtained on admission. Although the patient was treated for acute coronary syndrome and acute heart failure, her symptoms worsened. Results of emergency coronary angiography were normal. Echocardiography, however, showed left atrial enlargement, trivial mitral regurgitation, left ventricular diastolic dysfunction, left ventricular ejection fraction of 60%, asymmetrical …