A 32-years old female has presented with history of recurrent chest discomfort and left shoulder pain for 2 days. She has an acute stress at home regarding the health of her child and the symptoms started following this emotional outburst. The pain was not associated with sweating, shortness of breath or syncope. There was no past history of heart disease nor other conventional risk factors for ischemic heart disease like diabetes mellitus (DM), hypertension smoking, or illicit drug use. She has a history of gestational DM during her last pregnancy and has amenorrhea for 6 months. She was on diet and exercise regimen to lose weight since 6 months.
On physical examination she was obese with a BMI of 34 kg/sqm2. Her physical examination showed normal heart sounds and normal blood pressure. An electrocardiogram (ECG) was taken and it showed sinus rhythm with symmetrical T wave inversions in leads V1 to V6. [Figure 1] Cardiac troponin I which was 0.62 ng/ml (normal < 0.04ng/mL) at presentation peaked to 6.38 ng/mL subsequently normalized after 1 week suggestive of MI.
She was treated with aspirin, clopidogrel and enoxaparin injection in the emergency room. Her echocardiography was done and it showed hypokinesia of the mid and apical anterior septum and anterior wall with moderate left ventricular systolic dysfunction. She was taken up for coronary angiography on the next day. Her coronary angiography showed 75- % stenosis of the proximal left anterior descending coronary artery (LAD) and 50% lesion in the left circumflex coronary artery.(LCX) [Figure 2] She has undergone angioplasty and stenting to LAD with good result. [Figure 3] She remained pain free after the procedure. Serial ECGs showed normalization of the anterior wall ischemic changes [Figure 4] and normalization of the left ventricular function on follow up.
Routine blood investigation showed anemia with hemoglobin of 11g/dL with microcytic and macrocytic red blood cells (RBS) with hypochromia. She was evaluated for cause of anemia and it revealed both iron deficiency and vitamin B12 deficiency. As she has no conventional risk factors for atherosclerosis and young age of presentation, her serum homocysteine and lipoprotein A (Lp (a)) levels were assessed. Serum Lp (a) was normal and serum homocysteine levels were elevated at 28.48 micromoles/L.
She received vitamin B12 and iron supplementation and was started on folic acid for the hyperhomocysteinemia. The patient made a good recovery of her cardiac condition and improvement in anemia with normalization of the hemoglobin, blood pictures and vitamin B12. Her homocysteine level after 6 months of followup showed normal values suggesting that elevated homocystiene level was acquired due to nutritional deficiency of vitamin co -factors. She was advised to continue the started medication and to do lifestyle measures and she was followedup in the cardiology OPD and is doing well on follow up at 9 months.