Myocardial Infarction with Non-Obstructive Coronary Artery Disease: The Labyrinth of Investigations. Case Report and Review of the Literature.

Paul Simion,Ionut Achiței,Nicolae-Dan Tesloianu,Antoniu Octavian Petriș,Iulian Theodor Matei,Bogdan Artene

doi:10.3390/life11111181

Abstract

Myocardial infarction with non-obstructive coronary artery disease (MINOCA) accounts for approximately 5–15% of acute myocardial infarctions (MI). This infarction type raises a series of questions about the underlying mechanism of myocardial damage, the diagnostic pathway, optimal therapy, and the outcomes of these patients when compared to MI associated with obstructive coronary artery disease. We present the case of a 60-year-old patient with multiple cardiovascular risk factors and comorbidities who is admitted in an emergency setting. The patient is known with a conservatively treated inferior myocardial infarction which occurred 3 months prior, with reduced left ventricular ejection fraction. Emergency coronary angiography revealed normal epicardial coronary arteries, which led to further investigations of the underlying cause. Considering the absence of epicardial and microvascular spasm, CMR (cardiac magnetic resonance) confirmation of two transmural myocardial infarctions in the territories tributary to coronary arteries, and a high index of myocardial resistance in culprit arteries, we concluded the diagnosis of MINOCA due to the microvascular endothelial dysfunction. Although the concept of MINOCA was devised almost a decade ago, and these patients are an important part of MI presentations, it still represents a diagnostic challenge with multiple explorations required to establish the precise etiology.

Highlights

Myocardial infarction remains the leading cause of death and morbidity worldwide [1]. it is presumed that the absence of an artery blockage might imply a better prognostic, recent studies revealed that Myocardial infarction with non-obstructive coronary artery disease (MINOCA) patients tend to have the same or worse short-term prognosis compared to classic STEMI patients [2,3]
It is presumed that the absence of an artery blockage might imply a better prognostic, recent studies revealed that MINOCA patients tend to have the same or worse short-term prognosis compared to classic STEMI patients [2,3]
In the ACUITY trial, a total of 448 patients presenting with non-ST elevation myocardial infarction were included in the study (117 MINOCA and 331 with obstructive coronary disease), with no significant different baseline characteristics between the groups

Summary

Introduction

Myocardial infarction remains the leading cause of death and morbidity worldwide [1]. It is presumed that the absence of an artery blockage might imply a better prognostic, recent studies revealed that MINOCA patients tend to have the same or worse short-term prognosis compared to classic STEMI patients [2,3]. This can be explained by the difficulty in identifying a specific etiology and treatment. We are reporting an atypical STEMI presentation and step-wise clinical and imagistic decisions aiming to elucidate an obscure endothelial dysfunction in the myocardium microvasculature, which eventually leads to transmural infarction tributary to epicardial territories

Case Report

Findings

Discussion

Conclusions