Manifestation of Acute Coronary Syndrome in Critically Aortic Stenosis Patients

Abstract

The clinical presentation of acute coronary syndromes (ACS) is broad, from cardiac arrest, electrical or haemodynamic instability with cardiogenic shock (CS) due to ongoing ischaemia or mechanical complications such as severe mitral regurgitation, to patients who are already pain free again at the time of presentation. Critical aortic stenosis (AS) can cause inadequate myocardial perfusion and in the absence of demonstrable coronary stenosis or occlusion which resulting in ACS manifestation. Critical AS (defined as valve area <0.5 cm2) has been reported to cause mild increases in cardiac biomarkers such as troponin I. A 56-year-old man was admitted to hospital with chief complaint of typcal chest pain. Electrocardiogram (ECG) shows myocardial infarction in left main (LM) equivalent. Echocardiography revealed critical aortic stenosis. Cardiac marker also shows increasing. However, diagnostic coronary angiography (DCA) did not identify any lesions to account for the patient’s electrocardiographic changes and ongoing symptoms of chest pain. Consultation to cardiothorax surgeon to have urgent aortic valve replacement (AVR) were planned and underwent successful aortic valve (AV) replacement without coronary intervention. The definitive treatment for symptomatic severe AS is AVR. Some of the treatments that can be done are immediate coronary angiography and reperfusion procedure if there is suspicion of coronary artery occlusion or stenosis which may cause myocardial infarction; Intra-Aortic Ballon Pump (IABP) if there are signs of myocardial injury with take caution to the contraindications of IABP placement; Perform intervention procedure as soon as possible on aortic valve; Administration of medical therapy for heart failure in symptomatic severe AS patients. The case emphasizes the importance of initial physical examination, ECG, echocardiography, and cardiac markers as a whole that we do in aortic valve stenosis patient presenting with ACS.