Transmural myocardial infarction with "normal" coronary arteries

Coexistence of acute myocardial infarction with normal coronary arteries and migraine with aura in a female patient

Acute myocardial infarction with normal coronary arteries is a well known condition, which is typically diagnosed in young patients. Coronary vasospasm, inherited, acquired or malignancy-induced hypercoagulable state, collagen vascular disease and coronary arterial embolism have been considered as underlying etiologic factors. An association between migraine with aura and increased risk of ischemic stroke, angina and myocardial infarction has been demonstrated in studies. Patients with migraine and especially with aura should be followed closely against cardiovascular events even if they are young and do not have traditional risk factors.

Two brothers with myocardial infarction in the absence of atherosclerotic coronary artery disease: spontaneous coronary thrombosis: case reports of two brothers

Myocardial infarction in the absence of significant atherosclerotic coronary artery disease is not uncommonly encountered in clinical practice. This has been more often seen with the current sensitive biomarker assays for myocardial necrosis. Acute illnesses, spontaneous coronary dissection, sepsis, pulmonary embolism and coagulation disorders are some of the common clinical situation where elevated cardiac markers are noted. We describe two brothers presenting with acute myocardial infarction due to thrombus without any obvious cause.

A case of Takotsubo cardiomyopathy complicated by ventricular septal perforation

The patient was a 73-year-old female who developed chest pain and dyspnea 16 days after her husband passed away. ST segment elevation was detected on V2-5 by electrocardiography and emergency coronary arteriography was done for suspected acute myocardial infarction. No coronary arterial stenosis was present and ventricular septal perforation and takotsubo cardiomyopathy were diagnosed by left ventriculography. The perforation was closed and the patient was discharged 23 days after surgery. This patient had a very rare case of takotsubo cardiomyopathy, which was complicated by ventricular septal perforation and was saved by surgical treatment.

Near‐normal coronary angiography in a patient, who is entirely asymptomatic 24 years after successful intracoronary thrombolysis for ST elevation myocardial infarction. Follow‐up of the historically first Czech intracoronary thrombolysis patient

Extremely long-term follow-up (24 years) of the historically first Czech myocardial infarction patient, treated by intracoronary thrombolysis, is presented. His current coronary angiography confirmed the finding 24 years ago, that this was a case of smoking-induced thrombosis in otherwise healthy coronary arteries. Experience with 76 similar cases among 4093 consecutive coronary angiograms (including 778 done acutely for STEMI) is briefly described.

Occlusive vascular diseases in oral contraceptive users. Epidemiology, pathology and mechanisms

Despite being an unprecedented departure from normal physiology, the combined oral contraceptive is not only highly effective, but it also has a remarkably good safety record. Concerns over safety persist, though, particularly with regard to venous thromboembolism (VTE), stroke and myocardial infarction (MI). Epidemiological studies consistently show an increase in risk of VTE, but the results are more contentious with regard to arterial diseases. Despite 40 years of research, the mechanisms behind these adverse effects are not understood. In this review, we integrate information from published studies of the epidemiology and pathology of the occlusive vascular diseases and their risk factors to identify likely explanations for pathogenesis in oral contraceptive users. Oral contraceptives induce both prothrombotic and fibrinolytic changes in haemostatic factors and an imbalance in haemostasis is likely to be important in oral contraceptive-induced VTE. The complexity of the changes involved and the difficulty of ascribing clinical significance has meant that uncertainty persists. A seriously under-researched area concerns vascular changes in oral contraceptive users. Histologically, endothelial and intimal proliferation have been identified in women exposed to high plasma estrogen concentrations and these lesions are associated with thrombotic occlusion. Other structural changes may result in increased vascular permeability, loss of vascular tone and venous stasis. With regard to arterial disease risk, epidemiological information relating to dose effects and joint effects with other risk factors, and studies of pathology and changes in risk factors, suggests that oral contraceptive use per se does not cause arterial disease. It can, nevertheless, synergise very powerfully with subclinical endothelial damage to promote arterial occlusion. Accordingly, the prothrombotic effects of the oral contraceptive estrogen intervene in a cycle of endothelial damage and repair which would otherwise remain clinically silent or would ultimately progress - in, for example, the presence of cigarette smoking or hypertension - to atherosclerosis. Future work in this area should focus on modification of the effects of established risk factors by oral contraceptive use rather than modification of the supposed risk of oral contraceptive use by established risk factors. Attempts to understand vascular occlusion in oral contraceptive users in terms of the general features of VTE or with reference to atherosclerosis may be limiting, and future work needs to acknowledge that such occlusions may have unique features. Unequivocal identification of the mechanisms involved would contribute considerably to the alleviation of fears over vascular disease and to the development of even safer formulations.

Transient left ventricular aneurysm and hypertrophy accompanied by polymorphic ventricular tachycardia in a patient suspected of acute myocarditis

A 75-year-old woman presented with recurrent ventricular tachycardia (VT) compatible with torsades de pointes (TdP) based on sinus bradycardia and QT prolongation. Previously she had received pirmenol, at a serum concentration within therapeutic range, for her paroxysmal atrial fibrillation. Emergent cardiac catheterization identified a ventricular aneurysm of the anteroapical and inferior wall along with angiographically normal coronary arteries. A right ventricular endomyocardial biopsy revealed postmyocarditic change. The left ventricular contraction improved after 5 weeks of conservative treatment. A follow-up echocardiogram revealed transient thickening of partial left ventricular wall consistent with the segment of the aneurysm. Several months later, almost all abnormal findings had improved except for sustained deep negative T waves in precordial leads. Acute myocarditis was primarily suspected as the cause of her clinical presentation.

Myocardial infarction with angiographically normal coronary arteries

To determine the prevalence rate and clinical and hemodynamic profile of patients with myocardial infarction (MI) with angiographically normal coronary arteries, we analyzed 3,403 consecutive angiograms performed within a 4.5-year period. Of these studies, 1,124 were performed following an acute MI. Through a computerized search, 12 patients were identified who had documented MI with normal or insignificant (< 30% stenosis in one epicardial vessel only) coronary disease. Q-wave MI developed in five patients (group A) and non-Q-wave MI developed in seven patients (group B). Group A patients were all men whereas group B patients were all women. Overall, group A patients were younger (p = 0.003), had a longer smoking history (p = 0.008), and a higher cardiac index (p = 0.005). In ten patients, areas of localized dyskinesia or hypokinesia were shown on left ventricular cineangiography. Mitral valve prolapse was present in four of the patients and varying degrees of mitral regurgitation were identified in another six. The prevalence rate of MI with angiographically normal coronary arteries was 1% in this study. This entity had a bimodal age and sex distribution: a younger age group, all men, with a stronger cigarette smoking history who had Q-wave MI vs an older age group, all women, and no significant association with cigarette smoking who developed non-Q-wave MI. A mean follow-up of 4 years demonstrated a favorable prognosis in both groups.

Acetylcholine-induced myocardial ischemia without epicardial coronary artery spasm: a possible vasospasm of small coronary arteries--a case report

Small-vessel vasospasm has been speculated upon as a possible cause of chest pain in patients with normal-appearing coronary angiograms. In this report, a patient who experienced typical chest pain during acetylcholine testing, which caused ST segment elevation without epicardial coronary spasm, is presented. This finding suggests that small-vessel vasospasm may be involved in the induction of myocardial ischemia in patients with normal epicardial coronary arteries.

Cocaine-induced coronary artery disease: recognition and treatment

Recreational use of cocaine has reached epidemic proportions. Recent reports have linked cocaine use to various acute and chronic cardiovascular disorders. The pharmacology of cocaine is discussed in this article, and the experiences with cocaine-induced coronary artery disease reviewed.

Myocardial infarction and normal coronary arteriography: a 10 year clinical and risk analysis of 74 patients

Myocardial infarction with normal coronary arteries was identified in 74 patients with a mean age of 43 years (range 19 to 66). A mean follow-up period of 10.5 years after documented myocardial infarction and 8.6 years after cardiac catheterization was obtained. The survival rate was 85% (n = 63). There were no statistical differences in age or clinical risk factor prevalence between survivors and nonsurvivors. Moderate (55%) to severe (27%) left ventricular impairment was more common in nonsurvivors. Nine of 11 deaths were cardiovascular, 6 were sudden and 8 occurred in patients with moderate to severe global left ventricular impairment. Seventy-six percent of survivors were asymptomatic and 86% were fully active at follow-up. Two survivors and three nonsurvivors experienced a second myocardial infarction. The clinical risk factors of the study group (Group I) were compared by age, sex and year of catheterization with risk factors in two matched groups. Group II consisted of 74 patients with coronary occlusive disease and myocardial infarction and Group III consisted of 148 patients with normal arteriograms. Group I differed from Group II in having fewer clinical risk factors (p = 0.01 to less than 0.0001). Cigarette smoking did not differ significantly between Group I (72%) and Group II (69%) but was less common in Group III (45%) (p less than 0.001). Hormone therapy or the peripartum state was more common in women in Group I (34%) than in women in Group III (14%) (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Two cases of dilated cardiomyopathy complicated by left ventricular aneurysm

This report describes two patients with dilated cardiomyopathy associated with angiographically proven left ventricular aneurysm. There was no apparent history of myocardial infarction and coronary arteries were angiographically normal in both cases.

Recurrent myocardial infarction associated with cocaine abuse in a young man with normal coronary arteries: evidence for coronary artery spasm culminating in thrombosis

Myocardial infarction is increasingly recognized as a complication of cocaine abuse. A significant number of persons suffering from myocardial infarction associated with cocaine abuse do not have significant coronary atherosclerosis, and the mechanism for infarction in these patients has remained obscure. This report describes a young man with angiographically normal coronary arteries in whom cocaine abuse produced coronary artery spasm leading to coronary thrombosis and infarction.

Correlation of angiographic and surgical findings in distal coronary branches

In 60 consecutive patients undergoing vein graft surgery the angiographic appearances of the coronary vessels were compared with those of the vessels at operation. On the basis of lumen diameter at the potential sites for grafting it was possible to predict with reasonable accuracy from examination of the angiogram which vessels were large enough to be grafted. Angiographic predictive accuracy was 82% and was similar both for vessels which filled normally and for those which filled by collaterals. The predictive value of the angiographic assessment was similar for branches thought to be too small (predictive value 74%) and for those considered sufficiently large (predictive value 85%) to receive a vein graft. Disease of the vessel walls was found at surgery (66% of coronary branches examined) more frequently than was predicted from the angiographic appearances (33%). Previous necropsy studies have found a high prevalence of coronary atheroma in the population, yet normal angiographic appearances in the coronary arteries are not uncommon in patients undergoing investigation for suspected coronary disease. The present study showed that atheroma may be present in coronary vessels without encroaching into the vessel lumen, so that it is not evident on the angiogram. Coronary atheroma is thus present more often and is more widely distributed in the coronary tree than is indicated by coronary angiography.

Transmural myocardial infarction with normal coronary angiograms and with single vessel coronary obstruction. Clinical-angiographic features and five-year follow-up

Angiographic, clinical, and five-year follow-up study of 20 cases of myocardial infarction with normal coronary angiograms (MI-NCA) and 20 cases of myocardial infarction with single vessel obstruction (MI-SVO) are presented. MI-SVO patients differed from MI-NCA in being older (53.7 vs 44.5 years, p = 0.025), predominantly male (90 percent vs 40 percent, p = 0.001), frequently having large left ventricular akinetic segments (50 percent vs 15 percent, p = 0.01), and frequently having antecedent typical angina (55 percent). MI-NCA was more frequently associated with definite mitral valve prolapse (25 percent vs 10 percent, NS); migraine, or Raynaud's phenomenon (45 percent vs 5 percent, p = 0.001); birth control pill ingestion in women (33 percent vs 0 percent, p = 0.05); paroxysmal atrial flutter (25 percent vs 0 percent, p = 0.01); and antecedent atypical angina (25 percent). Frequency of cigarette smoking and hypertension and the mean serum cholesterol levels were similar in both groups. On follow-up, MI-NCA patients more commonly had neurologic events (25 percent vs 5 percent, p = 0.05) and second myocardial infarction (15 percent vs 0 percent, p = 0.02), but deaths occurred infrequently in both groups. These data suggest a variety of pathophysiologic causes for MI-NCA.

A case of normal coronary infarction after intracoronary thrombolysis with urokinase

We report the case of a 50-year-old male who had classical ECG signs of inferior wall myocardial infarction. Intracoronary thrombolysis resulted in fragmentation of a thrombus in the lumen of the right coronary artery. Angiography 1 month later showed no abnormalities at the site of previous thrombus. Ergonovine stress did not produce spasm. We conclude that (1) a mild cardial infarction can occur with an occlusive thrombus arising in angiographically normal coronary arteries; (2) transient change in minimal atheromata or spasm may induce such thrombi; and (3) thrombolytic therapy may be able to expedite recanalization of the occluded artery and salvage the myocardium.