Effect of tumor necrosis factor inhibitor treatment on proximal right coronary chronic total occlusion in a patient with rheumatoid arthritis.

Abstract

A 61-year-old man presented to the emergency department with acute anterior ST-segment myocardial infarction. A 12-lead ECG showed normofrequent sinus rhythm, a right bundle-branch block, significant ST-segment elevations in precordial leads V1 through V4 (Figure 1), and increased troponin I of 5.219 μg/L (normal range, 0–0.045 μg/L). Typical angina pectoris worsened during exercise to Canadian Cardiovascular Society grade II to III for almost 3 days and finally sustained at rest for the last 2 hours (Canadian Cardiovascular Society grade IV). Physical activity was markedly limited over the past weeks to New York Heart Association grade III. The patient´s cardiovascular risk profile consisted of active smoking status and arterial hypertension, whereas comorbidity was characterized by chronic obstructive pulmonary disease, and seropositive rheumatoid arthritis, as well (Figure 2). Daily medication consisted of methotrexate 15 mg (1 time/wk), folic acid (1 time/wk), torsemide (5 mg/d), and tiotropiumbromid and formoterol aerosol sprays. Figure 1. Initial 12-lead ECG demonstrated normofrequent sinus rhythm, a right bundle-branch block, and significant ST-segment elevations in precordial leads V1 through V4. Figure 2. Patient´s hands are affected by rheumatoid arthritis, as indicated by swollen joints, rheumatoid nodules, and palmar erythema. Primary coronary angiography revealed 3-vessel coronary artery disease with concomitant severe ectatic malformation of coronary vessels. The culprit lesion was a subtotal stenosis of the proximal left anterior descending artery with reduced thrombolysis in myocardial infarction flow (Figure 3A). The proximal part of the circumflex artery had a 90% stenosis, and the proximal left obtuse marginal artery did as well (Figure 3A). In addition, a chronic total occlusion (CTO) was verified at the proximal right coronary artery (RCA; thrombolysis in myocardial infarction flow 0; Movie I in the online-only Data Supplement) with retrograde filling from the left posterolateral artery through epimyocardial collaterals to the right posterior interventricular artery (Figure 3B and 3C; Movie …