Acute chest pain, ST Depression in V2 and V3, relief with Nitroglycerine, " normal " coronaries, and apical ballooning. Is it takotsubo?

This was submitted by Michael Fischer, one of our outstanding2nd year EM residents at Hennepin Healthcare.CaseA previously healthy female in her 40s presented 1 hour after abrupt onset 10/10 crushing chest pain that started while brushing her hair that morning. The pain radiated to her bilateral jaw and right shoulder, and did not seem to be exertional or pleuritic in nature.  Here is her pre-hospital ECG: What do you think?Smith: V2 and V3 have some minimal ST depression with downsloping.  This is highly suggestive of posterior MI.This was read by EMS as non-specific. Aspirin 324mg was given by EMS. Nitroglycerin spray x3 was also given which brought her pain down to 3/10 upon arrival to the ED. She was vitally stable with systolic BP of 140s. No cardiac history, not taking any medications, but does have 1st degree relatives with CAD.  Here is her first ED ECG:The ST Depression is more pronounced, and has extended to V4This was interpreted as ST-depression in V2-V4. Additional sublingual nitro was given x2, bringing her pain to 0/10 in her chest, however she still had pain in her jaw.  Given the abrupt onset of pain, aortic pathology was also a concern. Bedside echocardiography revealed grossly intact left ventricular function, non-dilated aortic root. Suprasternal view of the aorta revealed normal caliber aorta with no obvious dissection flap. Upper extremity pulses were equal. D-dimer was sent as further rule out for dissection. ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs