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Welcome to the European Society of Cardiology. Our mission: to reduce the burden of cardiovascular disease in Europe
 

Acute myocardial infarction in a young patient

Clinical case

Authors:

Hercules E. Mavrakis, Michael I. Hamilos, George E. Kochiadakis, Panos E. Vardas - Heraklion University Hospital, Crete, Greece

Educational Resource:

ESC Core Curriculum Chapter 8 (Acute Coronary Syndromes)


Case history: A 35-year-old woman who had delivered a child two weeks earlier, with an otherwise unremarkable medical history, was admitted to the outpatients department complaining of a two hour retrosternal pain with accompanying sweating and nausea. The physical examination revealed normal body temperature, 65 bpm heart rate and 130/75 mmHg arterial pressure. Heart sounds were normal and regular, with no murmurs. , The lung auscultation was normal. Peripheral pulses in the upper and lower extremities were clearly palpable. The ECG showed ST segment elevation in leads II, III, avF, V5, V6 with accompanying depression in leads V1-V3. The echocardiogram revealed hypokinesia in the basal and middle inferior wall segment of the left ventricle without any significant valvulopathy or pericardial fluid. The aortic root and ascending aorta were normal.

 

Question 1
What is the most possible diagnosis?
   
 






 

Although the patient received thrombolysis with reteplase neither the pain remitted, nor the ST elevations decreased. On the contrary, there was deterioration of the patients’ haemodynamic condition with hypotension, and a new ECG showed ST segment elevation in the right precordial leads (RV4-RV5).
 
 
 
Question 2
Which of the following diagnostic examinations should be performed next?
   
 





 

The patient was transferred to the Catheterization Laboratory in order to undergo coronary angiography. The coronary angiography revealed a normal left coronary artery with no atheromatic lesions, while the right coronary artery showed dissection along its entire length (Figure 1).


Question 3
Acute spontaneous dissection of a coronary artery is more common in:
   
 




 

 
Question 4
Mortality in acute spontaneous dissection of a coronary artery is:
   
 




 

 
Question 5
What is the commonest clinical presentation of acute spontaneous dissection of a coronary artery?
   
 





 

Question 6
Which of the following treatments is most controversial in acute coronary artery spontaneous dissection?
   
 





 

Conclusion

In the case of our patient angioplasty was immediately performed in the right coronary artery and 3 stents were sequentially placed (Figure 2, 3 and 4), with complete restoration of blood flow. After the completion of the angioplasty, the patient’s arterial pressure was restored with complete recession of the pain and the ECG elevations. The patient's course during hospitalization was complication – free. A mild increase of myocardial enzymes (CK-MB up to 52 IU/L, normal range:0-10 IU/L), typical for a small myocardial infarction, was observed, while the laboratory tests for possible immunological disease, were negative. Ten days after admission, the patient was discharged from the hospital in a good clinical condition. The patient, 13 months after angioplasty, remains asymptomatic.

References

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[2] European Association for Percutaneous Cardiovascular Interventions, Wijns W, Kolh P, Danchin N, Di Mario C, Falk V, Folliguet T, Garg S, Huber K, James S, Knuuti J, Lopez-Sendon J, Marco J, Menicanti L, Ostojic M, Piepoli MF, Pirlet C, Pomar JL, Reifart N, Ribichini FL, Schalij MJ, Sergeant P, Serruys PW, Silber S, Sousa Uva M, Taggart D; ESC Committee for Practice Guidelines, Vahanian A, Auricchio A, Bax J, Ceconi C, Dean V, Filippatos G, Funck-Brentano C, Hobbs R, Kearney P, McDonagh T, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Vardas PE, Widimsky P; EACTS Clinical Guidelines Committee, Kolh P, Alfieri O, Dunning J, Elia S, Kappetein P, Lockowandt U, Sarris G, Vouhe P, Kearney P, von Segesser L, Agewall S, Aladashvili A, Alexopoulos D, Antunes MJ, Atalar E, Brutel de la Riviere A, Doganov A, Eha J, Fajadet J, Ferreira R, Garot J, Halcox J, Hasin Y, Janssens S, Kervinen K, Laufer G, Legrand V, Nashef SA, Neumann FJ, Niemela K, Nihoyannopoulos P, Noc M, Piek JJ, Pirk J, Rozenman Y, Sabate M, Starc R, Thielmann M, Wheatley DJ, Windecker S, Zembala M.
ESC Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2010 Oct;31(20):2501-55

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[4] Jorgensen MB, Aharonian V, Mansukhani P et al. Spontaneous coronary dissection: a cluster of cases with this rare finding. Am Heart J 1994;127:1382-1387.

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Figures:

[Figure 1] Left anterior oblique projection of the right coronary artery. The dissection of the endothelium is obvious in the entire length of the vessel (arrows).

[Figure 2] Left anterior oblique projection of the right coronary artery. The blood flow in the right coronary artery is restored after stenting in the first third (white arrows). The stent was placed via a guide wire which had been placed in the branch for the right ventricle (black arrows).

[Figure 3 and 4] Left and right anterior oblique projection of the right coronary artery, respectively. After the placement of stents (white arrows) the lumen of the vessel is completely restored.