A 20-year-old normotensive male presented with sudden onset of near syncope, chest discomfort and dyspnoea. The patient has no known cardiovascular risk factors, including history of smoking, diabetes mellitus, dyslipidaemia and positive family history of ischaemic heart disease. Electrocardiogram (ECG) showed ST-elevation in the anterior and inferior leads (Panel A). Total white blood cell count was elevated at 16.9 x 109 /L with predominance of neutrophils (13 x 109 /L). Serum cardiac markers were also elevated: creatine kinase, 342 U/L; MB fraction, 24.3 ug/ L; troponin T, 1.01 ug/L. Initially, myocardial infarction (MI) was suspected. Emergent coronary angiography was performed and it was normal. Echocardiography revealed increased left ventricular (LV) wall thickness, hypokinesia in the inferior and inferolateral walls, preserved ejection fraction (EF) and mild pericardial effusion (Panel B). The patient was treated with anti-platelet therapies and investigated for possible causes of young MI. In addition, he was questioned for the possible use of cocaine which he denied. Serum levels of Lp(a), fibrinogen, anti-cardiolipin antibodies, anti-thrombin III, lupus anticoagulant and screen, protein C and S activities and activated protein C resistant test were normal.
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