Extreme ST-segment elevations in seemingly no significant angiographic coronary artery abnormalities: a case report
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Obstructive coronary artery disease is found in approximately 97% of patients presenting with ST-elevation myocardial infarction and 92% of patients with non ST-elevation myocardial infarction (Bainey KR, Welsh RC, Alemayehu W, Westerhout CM, Traboulsi D, Anderson T, et al. Int J Cardiol 264: 12–17, 2018). Recent studies showed that myocardial infarction without obstructive coronary atherosclerosis (MINOCA) is also associated with a long-term risk of adverse events (Bainey KR, Welsh RC, Alemayehu W, Westerhout CM, Traboulsi D, Anderson T, et al. Int J Cardiol 264: 12–17, 2018).. The following case illustrates that MINOCA may also be associated with short term adverse events (depending on the underlying mechanism).
A 49-year old Caucasian male with no significant medical history was referred to our cardiac emergency department with acute chest pain. The ambulance ECG showed extreme ST-segment elevation anterolateral (‘tombstone sign’), which had resolved completely at arrival in the hospital. Coronary angiography showed no obstructive coronary artery disease. Conservative (medical) therapy was started and patient was discharged. Two days later he presented with recurrent cardiac ischemia with ventricular fibrillation. Coronary angiography showed no changes compared with earlier presentation. During admission to the ICU his clinical condition gradually deteriorated, eventually leading to his death. Post-mortem studies showed no significant atherosclerotic lesions. Massive myocardial infarction was found, probably caused by temporary occlusion of the left main coronary artery.
Several pathophysiological mechanisms are recognized in MINOCA, of which vasospasm is the most probable one in this case. MINOCA is associated with increased over-all mortality and risk of ventricular arrhythmias. Therefore, additional testing should be considered when there is no explanation for the mismatch between ST-elevations (STEMI) and (no significant) coronary abnormalities.
KeywordsMINOCA STEMI Tombstone ST elevation Coronary spasm Case report
Angiotensin converting enzyme
Cardiac magnetic resonance imaging
Extra corporal life support
Fractional flow reserve
Intensive care unit
Instantaneous wave-free ratio
Left anterior descending coronary artery
Left main coronary artery
Myocardial infarction without obstructive coronary atherosclerosis
Non ST-elevation myocardial infarction
Percutaneous coronary intervention
Right coronary artery
ST-elevation myocardial infarction
Obstructive coronary artery disease is found in approximately 97% of patients presenting with ST-elevation myocardial infarction and 92% of patients with non ST-elevation myocardial infarction . Recent studies showed that myocardial infarction without obstructive coronary atherosclerosis (MINOCA) is also associated with a long-term risk of adverse events . The following case illustrates that MINOCA may also be associated with short term adverse events and may warrant further patient investigation regarding the underlying mechanism.
Two days later the patient presented at the emergency department after reanimation because of collapse due to ventricular fibrillation. Time of delay from onset until arrival of the ambulance was approximately 8 min. The ambulance ECG once again showed marked ST-elevations, which had resolved completely at hospital arrival. At arrival patient also had complete recovery of spontaneous circulation. An emergency coronary angiography was performed, which showed no changes compared to several days earlier and no clear cause of the VF. At first a conservative approach was chosen and the patient was admitted to the ICU. Intracoronary imaging (IVUS) of the LMCA was postponed awaiting neurological recovery.
Days since admission
Presentation with STEMI
Out of hospital cardiac arrest due to ventricular fibrillation
Emergency coronary angiography
Arrival on ICU: hemodynamically instable refractory ventricular tachycardia. Start extracorporeal life support
Stop extracorporeal life support
PCI LMCA – LAD
Long stay at ICU with clinical deterioration and no apparent neurological recovery
Patient died after treatment was stopped
The fore mentioned case left us wondering: what caused this man without any significant angiographic coronary lesions to present with such dramatic clinical consequences? Did we miss a significant lesion, did he have coronary spasms or is there another explanation?
Macroscopically the coronary arteries were open and showed no significant sclerotic lesions. The stent placed in the LMCA seemed to be open as well. On the Lactate dehydrogenase macroreaction (LDH) the entire left ventricle wall showed discoloration, with exception of the posterior wall. This finding indicates scarring and atrophy of the septum, anterior and lateral wall, indicating a massive myocardial infarction after occlusion of the LMCA. As the stent was not occluded the infarction probably occurred beforehand and was most likely the cause of the ventricular fibrillation at presentation.
Discussion and conclusions
This case is an extreme example of MINOCA (Myocardial Infarction with No Obstructive Coronary Atherosclerosis). Post-mortem findings showed clear signs of atherosclerotic changes in the LMCA and extensive infarction, where no significant angiographic lesions were visible. There were no signs of myocarditis or other explanations found for the rapid deterioration of the patient. Several pathophysiological mechanisms are recognized in MINOCA , of which vasospasm is the most probable one in this case.
Coronary spasms might be an explanation for this extreme presentation, as showed by previous case reports showing large infarctions due to spasms of the LMCA [3, 4]. The extreme elevations in our case could well fit spasms of either the LMCA or of both LAD and RCx. Further functional testing (such as spasm provocation testing) might have revealed additional information earlier on in this case. These tests however are not (and should not be) standardly performed in every patient. In patients presenting with extreme ECG or biochemical abnormalities without clear angiographic abnormalities though, these tests could be considered more readily.
Rupture of an eccentric plaque might be another possible explanation for MINOCA, although post-mortem findings do not support this theory in our patient. While angiographically no significant abnormalities were seen, postmortem findings did show an occlusion of 30–40% of the LMCA after stenting.
While the majority of patients presenting with a myocardial infarction has significant coronary artery disease, a significant proportion of patients shows no significant coronary abnormalities (a prevalence of 8.8% in NSTEMI is reported  and approximately 3% in STEMI ). One study in patients with MINOCA showed an increased prevalence of ventricular arrhythmia of 13.8% during hospitalization , especially in patients presenting with ST-segment elevation and patient who had transmural late gadolinium enhancement on CMR. Furthermore, non-obstructive coronary artery disease is associated with increased overall 1-year mortality (though mostly driven by greater non cardiac mortality) .
In conclusion myocardial infarction without obstructive coronary atherosclerosis is associated with increased over-all mortality and risk of ventricular arrhythmias. Therefore, additional testing should be considered when there is no satisfying explanation for the mismatch between ST-elevations (STEMI) and (no significant) coronary abnormalities.
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Availability of data and materials
MP main author. TF pathology examination and contributed in writing the post-mortem findings. JV proof reading and manuscript correction. All authors have read and approved the final version of the manuscript.
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