Unusual coronary flow in a patient with chest pain

A woman in her 70s with a history of breast cancer, undergoing chemotherapy with carboplatin and paclitaxel, is referred to the cardio-oncology clinic due to exertional dyspnoea and chest pain. Electrocardiography reveals T wave inversions in the precordial leads. Transthoracic echocardiography suggests apical hypertrophic cardiomyopathy (HCM), which is confirmed by cardiac MRI showing 15mm apical wall thickening, systolic apical obliteration (‘ace of spades’ morphology) and mid-wall late gadolinium enhancement. Stress imaging identifies a diffuse, reversible perfusion defect and coronary angiography reveals a tortuous left anterior descending (LAD) artery with prominent microvascular blush and drainage into the left ventricular (LV) cavity ( figure 1, online supplemental file 1). Adenosine testing demonstrates increased resting flow and impaired hyperaemic response.