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Myocardial infarction without significant coronary stenosis, transmural myocardial fibrosis at cardiac MR and non-obstructive high risk coronary atherosclerotic plaque at cardiac CT
Introduction and case report description We report the case of a 50 years-old man referred to our emergency department for suspected STEMI with late presentation. Invasive coronary angiography (ICA) was negative for significative coronary artery stenosis. A diagnosis of myocardial infarction (MI) with non-obstructive coronary plaque was made after a comprehensive evaluation, including cardiac MR and cardiac CT showing non-obstructive plaque with high-risk features on proximal LAD. Description of the problem, procedures, techniques and/or equipment used A 50 years-old man was referred to our center for STEMI with late presentation. He was asymptomatic and without known heart disease until one week before admission, when he suffered from oppressive chest pain. ECG showed sinus rhythm with ST elevation and Q waves on V1-V4 and inferior leads (Figure 1A). Blood analysis were normal apart from high-sensitive Troponin-I of 76 ng/l (v.n.<34 ng/l). Transthoracic echocardiography showed akinesia of antero-septal and antero-apical left ventricular (LV) wall with mild depression of LV systolic function. ICA showed no significative coronary lesion. Cardiac MRI confirmed mild LV dysfunction and showed transmural late gadolinium enhancement (ischemic pattern) on antero-septal and antero-apical LV wall (Figure 1B). Cardiac CT showed a non-obstructive plaque on proximal LAD with high-risk plaque characteristics (Figure 1C-1D). All different imaging modalities excluded atrial septal defect, patent foramen ovale and cardiac masses or vegetation, ruling out embolism as the cause of MI. Thus, type I MI, with non-obstructive coronary artery disease was the most appropriate diagnosis. Medical therapy with aspirin, high dose statin, ACE-inhibitors and beta-blocker was introduced. Questions, problems or possible differential diagnosis The main clinical problem in this patients was exclude myocarditis and to determine the most appropriate invasive and non-invasive treatment. Answers and discussion This case well represents how advance imaging modalities could be essential in the evaluation of patients presenting with suspected MI and normal ICA. In the case we present, after no significative coronary lesions was found at ICA, myocarditis was the main alternative diagnosis and it was clearly excluded after cardiac MRI showed transmural late gadolinium enhancement (ischemia pattern). The presence of non-obstructive plaque on proximal LAD with high risk features supported the hypothesis of type 1 MI as the most reasonable explanation to the clinical presentation. Thus, dual antiplatelet therapy and high dose statin is reasonable in these patients even if not supported by evidence. Conclusions and implications for clinical practice Cardiac MRI has a fundamental role in the management of patients with myocardial infarction and normal invasive coronary angiography. Moreover, cardiac CT could identify high risk non-obstructive plaque whose presence may be underestimated by ICA.
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