Rare cause of acute myocardial infarction. Age can be misleading sometimes

Introduction: Acute myocardial infarction represents a significant part of the life-threatening cardiovascular emergencies, a major public health issue that targets a large populational group. This pathology is characterized by phenotypic homogeneity. Spontaneous coronary dissection is a rare etiopathogenic mechanism of myocardial infarction, documented in medical literature mostly in isolated clinical case presentations, without a clear consensus about the therapeutic management.
Case presentation: A 31 year-old patient, occasional smoker, without family and cardiovascular history, pre-sented at emergency department of the territorial hos-pital with constrictive retrosternal pain, radiated to the left arm, accompanied by diaphoresis, started 2 hours before presentation. To be mentioned that during the same day, preceding the symptoms, the patient performed intense physical activity in unfavourable environment conditions (hot temperature). Electrocardiogram showed ST elevation in DI, aVL, V2-V6 with hyperacute, positive T waves in precordial derivations. Differential diagnosis was performed, taking into account acute myocarditis, but in the absence of a favourable clinical context, the diagnosis with the most severe prognosis was considered.
Intravenous thrombolysis with tenecteplase was administered in the territorial hospital, with electrocardi-ographic reperfusion criteria. Following thrombolysis, the patient was transferred in our clinic so as interventional exploration and revascularization if necessary to be performed.
Emergency diagnostic coronarography revealed spontaneous dissection with fold from the proximal to the medium segment of the anterior interventricular artery with a TIMI 2-3 distal flow. Percutaneous coro-nary angioplasty with drug-eluting stent was carried out at the level of the dissection with optimal final re-sult, TIMI 3 flow. After the procedure, electrocardio-gram showed accelerated idioventricular rhythm as an indirect sign of reperfusion. Laboratory tests revealed myocardial necrosis enzymes dinamics sugestive for acute myocardial infarction (CK-MB and TnI), witho-ut any other significant changes, notably normal lipid panel.
The patient was discharged on the seventh day with treatment recommendation with double antiplatelet therapy (acetylsalicylic acid and ticagrelor), statin, beta-blocker and angiotensin converting enzyme inhibitor, with cardiologic revaluation one month after infarction.
Particularities and discussion: T his presented case brings in discussion differential diagnosis issues in a group of patients in which the incidence of atherosclerotic coronary pathology is low. Moreover, the topic regarding the therapeutic management should be de-bated: thrombolysis with the associated haemorrhagic risk followed by coronary angioplasty and stenting of a coronary artery without evident atherosclerotic invol-vement. Furthermore, the necessity of double antipla-telet medication for at least one year and statin therapy at a young age may generate discussions. The patient’s age is not represented on the SCORE risk map of the European Society of Cardiology designed to establish cardiovascular risk. Last but not least, the non-athe-rosclerotic etiology where intense physical activity was the trigger and discrete endothelial dysfunction was a favourable factor should be analysed.
Conclusions: This case illustrates the rare scenario in which a young patient without strong cardiovascular risk factors suffers a severe acute myocardial infarction. Non-atherosclerotic etiology is more frequently descri-bed in peri- or postpartum cases. In medical literature there are several cases of myocardial infarction produ-ced by this etiopathogenic mechanism in the context of intense physical exertion. Therefore, a thorough anam-nesis is essential in every patient with chest pain. Mai-ntenance of a high suspicion level might be decisive in saving a life.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)