Presentation
A 25-year-old male visited the emergency department with intermittent chest tightness lasting nine hours. He reported pain localized to the anterior chest, radiating to the left back. The pain episodes were lasting from a few seconds to several minutes. The pain occurred without any trigger. The patient had no associated symptoms like dizziness, headache, vision changes, syncope, sweating, gastrointestinal issues, or abdominal discomfort. His medical history included more than five years of known but untreated elevated blood glucose levels. The medical history of the patient reported strong family history of hereditary diabetes. However, he had no history of hypertension, heart disease, or smoking.
Examination
On arrival, the patient was stable and the physical examination was normal. The initial electrocardiogram (ECG) showed sinus tachycardia and inverted T waves in leads II, III, and aVF. Cardiac biomarkers (creatine kinase-MB (CK-MB), myoglobin (MYO), troponin T (TnT), and NT-proBNP) were normal. D-dimer was also normal.
Diagnosis
The chest pain was suggested due to coronary artery disease or myocarditis .Type 2 diabetes mellitus (T2DM) was also suspected. The patient was treated with aspirin, atorvastatin, clopidogrel, metoprolol succinate, and isosorbide mononitrate to manage chest pain and reduce cardiovascular risk. After two hours, the chest pain worsened and radiated to the left shoulder and back. A repeat ECG showed ST-segment elevation in leads I, II, aVL, and V2–V6.Although cardiac enzymes remained within normal limits, chest pain suspected acute coronary syndrome. An emergency coronary angiography was performed. The patient had no stenosis in the left main coronary artery, left circumflex artery, or right coronary artery. However, a myocardial bridge was observed in the mid-portion of the left anterior descending artery, with about 40% systolic compression. Blood flow in all coronary arteries was preserved (TIMI grade 3).Chest pain gradually resolved after the procedure.
Further Evaluation
Additional tests confirmed a diagnosis of type 2 diabetes mellitus. The HbA1c level of the patient was 9.6%.An oral glucose tolerance test (OGTT) showed fasting, 1-hour postprandial, and 2-hour postprandial glucose of 9.94 mmol/L, 19.78 mmol/L, and 22.79 mmol/L, respectively. Insulin and C-peptide testing demonstrated a delayed insulin peak, indicating insulin resistance. A 24-hour Holter ECG showed sinus rhythm with an average heart rate of 88 bpm, intermittent ST-segment elevations, ST-T changes, and reduced heart rate variability. Cardiac MRI showed normal left ventricular size and function; however, there was a reduced extracellular volume and delayed myocardial perfusion in some segments.
Management
The final diagnoses were variant angina caused by myocardial bridging and type 2 diabetes mellitus with autonomic dysfunction. The patient was treated with acarbose 50 mg once daily, metformin 500 mg once daily, aspirin 100 mg daily, atorvastatin 10 mg daily, metoprolol succinate 47.5 mg daily, and nicorandil 5 mg daily. His chest pain improved, and blood glucose levels started stabilizing. After six days of hospital care, the patient was discharged.
Follow-Up
The patient had stable blood glucose levels and had no recurrence of chest pain. He was on the prescribed antidiabetic and cardiovascular medications.
