Resting Dyspnea, Regional Wall Motion Abnormality, and Normal Coronary Angiography in a Hypertensive Patient: A Diagnostic Dilemma
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Abstract
Background: Progressive dyspnea in a hypertensive patient with echocardiographic regional wall motion abnormality frequently raises suspicion of obstructive coronary artery disease and may lead to invasive coronary evaluation. However, regional wall motion abnormality is not always synonymous with stentable epicardial coronary disease, particularly in patients with long-standing hypertension, chronic alcohol exposure, and renal dysfunction. Case Presentation: A 55-year-old male graphic designer with long-standing systemic hypertension, chronic alcohol consumption, and baseline renal dysfunction with serum creatinine around 2 mg/dL presented with gradually progressive breathlessness over several years, recently worsening to dyspnea even at rest. A non-invasive coronary CT performed approximately six months earlier was reportedly normal. During the current evaluation, laboratory investigations showed serum creatinine of 1.92 mg/dL and hyperuricemia. Two-dimensional echocardiography revealed regional wall motion abnormality with mild left ventricular systolic dysfunction, left ventricular ejection fraction around 45%, and mild mitral regurgitation. In view of worsening symptoms and suspected ischemic myocardial involvement, coronary angiography with possible stenting was planned. Considering his renal dysfunction, contrast volume was minimized. Surprisingly, invasive coronary angiography showed normal epicardial coronary arteries, and no stent was placed. The patient was subsequently managed conservatively with optimized antihypertensive therapy, heart-failure-directed medical treatment as tolerated, renal monitoring, lifestyle modification, and alcohol cessation counseling, following which he showed symptomatic improvement. Conclusion: This case highlights the diagnostic discordance between dyspnea, echocardiographic RWMA, and normal coronary anatomy. In hypertensive patients with chronic alcohol use and renal dysfunction, normal coronary angiography should prompt consideration of hypertensive heart disease, alcohol-related myocardial dysfunction, coronary microvascular dysfunction, and ischemia with non-obstructive coronary arteries rather than premature dismissal of symptoms. Keywords: Hypertension; dyspnea; regional wall motion abnormality; normal coronary angiography; INOCA; alcoholic cardiomyopathy; chronic kidney disease.
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