Myocardial infarction with non-obstructive coronary arteries in young women presenting with ST-segment elevation myocardial infarction: a case series
, 23, 23, 123
Abstract
Introduction. Myocardial infarction with non-obstructive coronary arteries (MINOCA) is an increasingly recognised entity, with comparable mortality to myocardial infarction with obstructive coronary artery disease (CAD).
Case presentation. We present the cases of two young females presenting to hospital with ST-segment elevation myocardial infarction without obstructive CAD. Common to both cases was the acute onset of chest pain with no prior cardiac history, minimal cardiac risk factors, and the use of hormone-based contraception. The first patient had an ostially occluded left anterior descending artery (LAD). Flow was restored with balloon inflation and the administration of tirofiban. However, no underlying obstructive CAD was identified, which was confirmed with repeat angiography and optical coherence tomography. The cause was later attributable to plaque erosion, after learning the results of a normal thrombophilia screening. The second patient had ST-segment resolution on arrival to the catheter lab, and on angiography, she had TIMI II flow down the LAD due to significant thrombus burden. Similarly, balloon inflation and tirofiban were administered to improve flow, and non-obstructive CAD was confirmed with repeat angiography and OCT 48 hours later. As with patient 1, this patient too had normal thrombophilia screening results. Both patients were discharged with dual-antiplatelet therapy and secondary prevention, and were advised
against hormone-based contraception.
Discussion. Patients with MINOCA tend to be younger, with a higher female-to-male preponderance. Multiple causes have been identified, highlighting the importance of following a diagnostic algorithm. This will enable correct treatment, which may differ from that for patients with obstructive coronary disease, thus improving prognosis.
Keywords: MINOCASTEMIOCTthrombus
References
- Pasupathy S, Air T, Dreyer RP, et al. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation. 2015; 131(10): 861–870.
- Xie Y, Mintz GS, Yang J, et al. Clinical outcome of nonculprit plaque ruptures in patients with acute coronary syndrome in the PROSPECT study. JACC Cardiovasc Imaging. 2014; 7(4): 397–405.
- Tonino PAL, De Bruyne B, Pijls NHJ, et al. FAME Study Investigators. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009; 360(3): 213–224.
- Beltrame JF, Crea F, Kaski JC, et al. Coronary Vasomotion Disorders International Study Group (COVADIS). International standardization of diagnostic criteria for vasospastic angina. Eur Heart J. 2017; 38(33): 2565–2568.
- Tamis-Holland JE, Jneid H, Reynolds HR, et al. American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; and Council on Quality of Care and Outcomes Research. Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association. Circulation. 2019; 139(18): e891–e908.