A particular case of acute coronary syndrome in a young patient

Introduction: There are significant differences in the clinical manifestation of coronary heart disease in the young compared to older people. Young people usually present with ST elevation myocardial infarction and the coronary arteries may be normal or with minimal atherosclerotic lesions.
Case presentation: We present the case of a 43 year-old man transferred to our unit for ventricular fibrillation resulting in cardiac arrest, successfully resuscitated. He was an active smoker, was dyslipidemic and overweight, had a family history of sudden cardiac death, but no significant history of cardiovascular disease. Of note, the patient had a recent history of angina and the ECG before the cardiac arrest revealed ST segment elevation in V1-V3 leads with mirror image in inferior leads. Emergent coronary angiography showed coronary arteries without significant lesions (minimal infiltration of the proximal anterior descending artery and of the obtuse marginal artery) so that the patient received only pharmacological treatment. Biomarkers compatible with cardiomyocite injury were positive and another episode of angina was noted during the hospital stay, with an ECG similar to the one recorded before the cardiac arrest. This episode was successfully treated with nitrates. The transthoracic echocardiography showed minimal wall motion abnormalities and the 24 hour ECG recording revealed sinus rhythm, without notable abnormalities. Therefore, a diagnosis of STEMI secondary to prolonged coronary vasospasm was made and the patient was discharged with a long-term treatment consisting of platelet inhibition therapy, statin, angiotensin enzyme inhibitor, calcium blocker, nitrate and antiarrhythmic drugs, with the indication of readmission for an implantable cardiac defibrillation necessary for secondary prevention. The patient was readmitted to out unit one year later because of reoccurrence of angina, this time without elevation of cardiomyocite injury biomarkers. He denied treatment cessation or substance abuse that might induce coronary vasospasm. Thus, the dose of calcium blockers and nitrates was increased and the patient remained asymptomatic. A cardiac MRI was performed and re-vealed no areas of scar or abnormal tissue. The patient presented to our unit for the third time because of an-gina reoccurrence under enhanced anti-ischemic treatment. No ECG abnormalities were noticed. During the admission period the patient developed minimal ST segment elevation with biphasic T waves in V1-V3 le-ads. The subsequent coronary angiography revealed a 90% stenosis of the proximal ADA, reduced to 50% af-ter administration of nitrate. Optical coherence tomography was performed for a better description of the lesion and a drug eluting stent was implanted. Following the procedures, the patient received platelet inhibition therapy, statin, angiotensin enzyme inhibitor, calcium blocker, with favorable subsequent evolution.
Particularity of the case: Acute myocardial infarction complicated with ventricular fibrillation was the con-sequence of a prolonged coronary spasm in a young patient, with a small number of cardiovascular risk factors. Furthermore, the initial coronarography revealed no significant coronary artery disease.
Conclusion: In order to establish the cause of a myocardial infarction with non-obstructive coronary arteries (MINOCA), new techniques are necessary. Optical coherence tomography is the ivestigation that described the coronary lesion that could not be visualised by means of conventional angiography and allowed stent implantation that could cover the entire unstable atherosclerotic plaque.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)