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Published on: May 28, 2019
Young ST-Segment Elevation Myocardial Infarction With Autolysis: Survival of the Blessed
Preetika Maurya1, Aditi Newaskar2, Krishna Prasad Nevali3
1Department of Cardiology, Base Hospital, New Delhi, India.
Insights
Young patients with ST-elevation myocardial infarction (STEMI) experiencing autolysis during primary percutaneous coronary intervention (PPCI) may not require stenting. Optical coherence tomography (OCT) aids in understanding STEMI
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Biology
Background:
- ST-elevation myocardial infarction (STEMI) in young patients presents unique management challenges.
- Autolysis can lead to spontaneous thrombus resolution, resulting in patent arteries with TIMI flow grade 3 during primary percutaneous coronary intervention (PPCI).
- This phenomenon requires careful consideration for optimal treatment strategies.
Observation:
- Case series involving three young male patients presenting with STEMI.
- During PPCI, all patients exhibited thrombus in the left anterior descending artery (LAD) with TIMI flow grade 3.
- Stenting was deferred in all cases, with subsequent follow-up via coronary angiography (CAG) and optical coherence tomography (OCT).
Findings:
- Repeat CAG after 4 weeks demonstrated complete thrombus resolution in all patients.
- OCT revealed healed plaque rupture, plaque erosion, and intramural hematoma in the respective cases.
- Successful medical management without stent placement was achieved.
Implications:
- Young STEMI patients with favorable autolysis profiles during PPCI may be managed conservatively without stenting.
- Optical coherence tomography (OCT) is crucial for elucidating the pathophysiological mechanisms of STEMI in these cases.
- This approach offers a new perspective on managing selected young STEMI patients, potentially avoiding unnecessary interventions.
Background:
Many times, young patients with ST-segment elevation myocardial infarction (STEMI) are angina free during primary percutaneous coronary intervention and have patent infarct-related artery with TIMI flow grade 3 due to the process of autolysis. These cases pose a great challenge to the interventionist mind. This case series provides a new perspective to the management of such patients.
Case Summaries:
Patient 1 is a 31-year-old man who presented with STEMI. During primary percutaneous coronary intervention (PPCI), thrombus laden left anterior descending artery (LAD) with TIMI flow grade 3 was noted. Stenting was deferred and repeat coronary angiogram (CAG) after 4 weeks showed resolved thrombus and optical coherence tomography (OCT) showed healed plaque rupture. Patient 2 is a 29-year-old man who presented with STEMI of 12 hours' duration. During PPCI, mid-LAD had thrombus and TIMI flow grade 3. Stenting was deferred, and antithrombotic therapy was given. Repeat CAG showed complete resolution of thrombus, and OCT showed features of plaque erosion with adequate luminal areas. Patient 3 is a 31-year-old man undergoing treatment for nonseminomatous germinal cell tumor who presented with STEMI. During PPCI, LAD had nonocclusive thrombus with TIMI flow grade 3. Stenting was deferred and managed medically. CAG 4 weeks later showed resolution of thrombus and adequate luminal areas with a healing intramural hematoma on OCT.
Discussion:
Young STEMIs with features of autolysis during PPCI may be managed without stent placement if they have a favorable autolysis profile. OCT in these patients helped to understand the underlying pathophysiological mechanism of STEMI.
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