A 54-year-old man with only a history of hypertension was admitted to our hospital with acute chest pain radiating to the left arm. His electrocardiogram showed ST-segment deviation and dynamic negative T-waves in leads V1–V3, and laboratory results demonstrated elevated troponin-T levels with a typical rise and fall, indicating a non-ST-elevation myocardial infarction. Coronary angiography was performed, revealing no significant coronary artery disease or culprit. Consequently, anticoagulant medication was stopped and he was diagnosed with a myocardial infarction with no obstructive coronary arteries (MINOCA).
In the outpatient clinic, he mentioned recurrent anginal complaints, for which a cardiac magnetic resonance scan was requested. First pass stress perfusion ruled out ischaemia; however, the late gadolinium enhanced images exposed subendocardial basal- and mid-septal hyperenhancement, suggestive of a prior endured focal myocardial infarction (Panels A and B). After critical re-appraisal of the previous coronary angiogram, one can identify a subtle occlusion of the first septal branch of the left anterior descending artery, also matching the previous electrocardiogram (Panels C and D, Supplementary material online, Moving Image A). Importantly, secondary prevention was re-initiated, including lifestyle modifications.
This case underlines that early cardiac magnetic resonance imaging (MRI) is indispensable in the work-up of patients with MINOCA, which can lead to definite diagnosis and potential adjustments for improved (medical) therapy.
Supplementary material is available at European Heart Journal online.
Conflict of interest: P.D. has received consultancy fees from Philips and Abbott and has received research grants from Philips, Abbott, and AstraZeneca. R.N. has received consultancy fees from Sanofi Genzyme and Bayer and has received research grants from Philips and Biotronik. T.P.J.J. has received a research grant from Abbott.
Supplementary Material
Contributor Information
Tijn P J Jansen, Department of Cardiology, Radboudumc, Nijmegen, Netherlands.
Peter Damman, Department of Cardiology, Radboudumc, Nijmegen, Netherlands.
Robin Nijveldt, Department of Cardiology, Radboudumc, Nijmegen, Netherlands.
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