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Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Extreme ST-segment elevations in seemingly no significant angiographic coronary artery abnormalities: a case report
M Piels1,2, T Faes3, J Vainer3
1Maastricht University Medical Center (MUMC+), P. Debyelaan 25, 6229HX, Maastricht, The Netherlands. marc.piels@mumc.nl.
Insights
Myocardial infarction without obstructive coronary atherosclerosis (MINOCA) can lead to severe short-term adverse events, including death. This case highlights the critical need for further investigation into MINOCA
Area of Science:
- Cardiology
- Internal Medicine
- Pathophysiology
Background:
- Obstructive coronary artery disease is prevalent in ST-elevation myocardial infarction (STEMI) and non-STEMI.
- Myocardial infarction without obstructive coronary atherosclerosis (MINOCA) presents a diagnostic challenge.
- MINOCA is linked to long-term adverse events, but short-term risks are less understood.
Observation:
- A 49-year-old male presented with acute chest pain and ST-elevation myocardial infarction.
- Coronary angiography revealed no obstructive coronary artery disease.
- The patient experienced recurrent ischemia, ventricular fibrillation, and ultimately died, with post-mortem findings indicating massive myocardial infarction likely due to temporary left main coronary artery occlusion.
Findings:
- This case demonstrates that MINOCA can be associated with severe short-term adverse events.
- Vasospasm is a potential underlying mechanism for MINOCA.
- MINOCA is associated with increased mortality and ventricular arrhythmias.
Implications:
- When ST-elevations are present without significant coronary abnormalities, further diagnostic testing for MINOCA is crucial.
- Understanding the underlying mechanisms of MINOCA is vital for timely and effective patient management.
- Early identification and management of MINOCA can potentially improve patient outcomes and reduce mortality.
Background:
Obstructive coronary artery disease is found in approximately 97% of patients presenting with ST-elevation myocardial infarction and 92% of patients with non ST-elevation myocardial infarction (Bainey KR, Welsh RC, Alemayehu W, Westerhout CM, Traboulsi D, Anderson T, et al. Int J Cardiol 264: 12-17, 2018). Recent studies showed that myocardial infarction without obstructive coronary atherosclerosis (MINOCA) is also associated with a long-term risk of adverse events (Bainey KR, Welsh RC, Alemayehu W, Westerhout CM, Traboulsi D, Anderson T, et al. Int J Cardiol 264: 12-17, 2018).. The following case illustrates that MINOCA may also be associated with short term adverse events (depending on the underlying mechanism).
Case Presentation:
A 49-year old Caucasian male with no significant medical history was referred to our cardiac emergency department with acute chest pain. The ambulance ECG showed extreme ST-segment elevation anterolateral ('tombstone sign'), which had resolved completely at arrival in the hospital. Coronary angiography showed no obstructive coronary artery disease. Conservative (medical) therapy was started and patient was discharged. Two days later he presented with recurrent cardiac ischemia with ventricular fibrillation. Coronary angiography showed no changes compared with earlier presentation. During admission to the ICU his clinical condition gradually deteriorated, eventually leading to his death. Post-mortem studies showed no significant atherosclerotic lesions. Massive myocardial infarction was found, probably caused by temporary occlusion of the left main coronary artery.
Conclusions:
Several pathophysiological mechanisms are recognized in MINOCA, of which vasospasm is the most probable one in this case. MINOCA is associated with increased over-all mortality and risk of ventricular arrhythmias. Therefore, additional testing should be considered when there is no explanation for the mismatch between ST-elevations (STEMI) and (no significant) coronary abnormalities.
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