CORONARY DISEASE. E.J. Lee 1 , K. Barnard 1 ; 1 University of Pittsburgh, Pittsburgh, PA (Tracking ID #75596) LEARNING OBJECTIVES: Recognize gender differences in the presentation of myocardial ischemia and consider microvascular spasm as a cause for chest pain in women with angiographically normal coronary arteries. CASE INFORMATION: A 54 year-old Asian-American woman with history of chronic back pain presented with retrosternal chest pain. The pain was sharp, radiated to her left arm, awoke her from sleep, and lasted for one hour. She had had similar pain the previous day, lasting an hour before spontaneously resolving. Neither episode was associated with nausea, vomiting, diaphoresis, or exertion. Another similar episode occurred one year ago. Echocardiogram at that time showed mild hypertrophy and normal overall function, while coronary catheterization revealed normal coronary arteries and an ejection fraction of 65%. The patient had no history of diabetes, hypertension, hyperlipidemia, smoking or family history of coronary artery disease. On initial evaluation in the Emergency Department, the patient was without chest pain. Her electrocardiograph showed normal sinus rhythm with no ischemic changes. Chest radiograph was normal. Total CPK was 71 and troponin was less than 0.2. She was admitted to rule out myocardial infarction. Shortly after being admitted, the medicine house staff were called to evaluate the patient for``seizure-like activity.'' The patient was found in severe emotional distress with taut extension of her upper and lower extremities, and clawing of her hands bilaterally. She was alert, oriented, and able to follow commands throughout this episode which resolved within minutes. Electrolytes showed a calcium of 9.7, magnesium of 1.7, phosphate of 3.3, and potassium of 3.8. An electrocardiograph at this time showed ST depression in leads II, III, and AVF. Repeat electrocardiograph showed a similar pattern of ST depressions. The patient was transferred to the cardiac step-down unit with a presumptive diagnosis of unstable angina and started on anticoagulation therapy. Aspirin and beta-blockers were held due to reported allergies. Subsequent electrocardiographs showed normal ST segments in all leads. Second and third sets of cardiac enzymes were negative. Cardiac catheterization the following day revealed normal coronary arteries and an ejection fraction of 60%. The patient was discharged home the following day in good condition. IMPLICATIONS/DISCUSSION: There is abundant data to suggest there are gender differences in the risk factors, presentation, and management of cardiac disease. It has been shown that negative affect and emotional distress may increase risk of ischemic heart disease and interfere with effective cardiac rehabilitation. Mental stress has been known to cause ischemic changes on electrocardiograph and abnormalities in regional and global left ventricular function. These effects have been associated with microvascular spasm. A mental stress-induced ischemic episode may have occurred in this patient. A coronary catheterization that showed normal coronary flow would not be uncommon in such a case. It is important to realize that despite angiographically normal coronary arteries, this may be an atypical presentation of true underlying coronary disease.