This is a true story . . . happened many years ago under my direct vision.
A 48 year old women came with significant breathlessness and catchy sub -sternal chest pain .
“I was exerting too much in recent days doctor” , she said .
Her ECG showed a tachycardia and dramatic ST depression in most leads .
The ER in charge promptly texted the cardiologist .
The moment he saw the ECG ,he had no hesitation , to order for an emergency angioplasty ( How can he plan a angioplasty , without even knowing the coroanry anatomy . some one murmured . May be . . what he probably meant was emergency angiogram the other explained ) Further , he was telling his fellows . . . that this is going top be tough case and a possible left main PCI .
An emergency angiogram was done . On table it was a huge surprise for every one , it was a a classical text book look alike normal coronary arteries !
The moment normal CAG was visualized the consultant concealed his momentary surprise and went on to say it is classical case of syndrome X with severe micro- vascular disease causing ECG changes !
As the patient did not give any opportunity to poke her coronaries she was wheeled out of wheeled out of cath lab.
Meanwhile , first year fellow came rushing with the blood reports and biochemistry .
Is everything alright ? Yeh sir , except her Hb % . . . it is 5.6 Grams !
The bewildered consultant * realized the high coronary drama , that is been enacted over the past 2 hours ! and learnt (and taught) a most important lesson to their fellows !
Hi guys , this is neither a NSTEMI nor a microvascular syndrome X . . . this is simply anemia related extreme ECG changes ! We have erred in our reasoning and our pre cath clinical scrutiny has gone awry !
He went on to say , don’t worry many times medicine is learnt in hard ways . After all nothing adverse has happened here .
The women was subsequently investigated and handed over to gynecologist for a probable hysterectomy .
Final message
Please be reminded , anemia can produce variety of ECG changes. In extreme anemia global ST depression is common especially if tachycardia is associated .
The lesson here is , whenever gross ST depression is witnessed with vague chest pain check the hemoglobin first . This is an unusual story of a women , with simple anemia (due to chronic mennorhagia ) landed in cath table in an acute fashion . Luckily she did not have any incidental coronary lesions that prevented her becoming a greater cath lab victim !
* The bewildered consultant is none other than the author of this blog.
Dr.S.Venkatesan MD 
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