Myocardial infarction in a patient with normal coronary arteries

Mr DM, a 71-year-old retired hospital administrator, telephones his local GP on a weekday morning as he is experiencing an episode of severe central, nonradiating chest pain. His GP advises him to call an ambulance immediately.

When Mr DM arrives in your emergency department (ED), you see that his vital signs are within normal limits except for sinus tachycardia (heart rate, 105 beats per minute). He is transferred to an acute bed.

Mr DM tells you he is currently pain-free but has had four days of intermittent chest pain that he rates as up to 7/10 in severity, which is relieved by rest and use of his wife’s glyceryl trinitrate spray. Although his pain sounds typically cardiac, you confirm that he has no risk factors for pulmonary emboli. His ECG shows sinus rhythm with 2 mm of horizontal anterolateral ST depression but no other abnormalities.

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