An unusual cause of recurrent chest pain in a highly trained recreational athlete

Here, the case of a 48-year-old highly trained patient without classic myocardial risk factors is described who reported on frequent and recurrent angina pectoris. In a previous examination, the test for cardiac troponin T (cTnT) was slightly positive, however, cardiac examination including myocardial perfusion scintigraphy and coronary catheterization was without pathologic findings. Worth mentioning in the past medical history was a rheumatoid arthritis with persistent Raynaud's symptoms and hemoglobin as well as hematocrit levels in the upper normal range. The patient reported that symptoms would occur most likely during long-term endurance exercise. Therefore, a bicycle ergometry with 180 W and open ending was performed. After 1.55 h, the patient complained of severe angina pectoris. The ECG showed massive ST segment elevations in II, III, and aVF (Figure 2). However, coronary catheterization showed no major stenosis or occlusion. Nevertheless, cTnT increased to 0.979 ng/ml. (Therefore, the reason for the symptomatic ST elevation was believed to be a myocardial tissue damage due to coronary vasospasm and the patient received an antivasospastic medication (amlodipine, atorvastatin, and acetylsalicylic acid [ASS]). After 6 months, the patient had a relapse during moderate physical activity. The ECG showed an ST segment depression in V(4) and V(5) while markers for myocardial tissue damage including cTnT were negative. A coronary CT angiography was performed that revealed a subtotal stenosis of the proximal LAD (Fig ure 3), which was successfully treated by angioplasty with subsequent stenting. In the course of further examinations, a polycythemia vera (JAK2-V617 mutation) was diagnosed as the cause for the high hemoglobin and hematocrit levels. Since then, the patient was without further events under a medication consisting of ASS, atorvastatin, candesartan, and intermittent phlebotomy. Although a relative weighting is difficult, it can be assumed that the combined effects of a polycythemia- associated hypercoagulability, an increased reagibility of the coronary arteries (aggravated by physical stress) as well as a hemoconcentration following prolonged exercise, could account for symptomatic recurrent minor thrombotic coronary events as well as the subtotal occlusion of the LAD. Obviously, this could not be prevented by a healthy lifestyle, regular physical activity, and the absence of classic coronary risk factors.