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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 22  |  Issue : 4  |  Page : 293-296  

Myocardial infarction with non-obstructive coronary arteries: To stent or not to stent? That is the question


Mohammed Bin Khalifa Specialist Cardiac Centre (MKCC), Awali, Kingdom of Bahrain

Date of Submission19-Feb-2021
Date of Acceptance18-Dec-2021
Date of Web Publication11-Feb-2022

Correspondence Address:
Dr. Seham Abdulrahman
Mohammed Bin Khalifa Specialist Cardiac Centre (MKCC), Awali
Kingdom of Bahrain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_28_21

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   Abstract 


Myocardial infarction with nonobstructive coronary arteries (MINOCA) in the context of acute ST elevation myocardial infarction (STEMI) is a challenging situation with no clear guidelines. In the absence of a consensus, optical coherence tomography (OCT) provides a better well-informed decision whether to stent or not. Herein, we report a case of MINOCA that underwent stenting of the proximal left anterior descending artery in the setting of extensive anterior wall STEMI in view of high-risk clinical presentation and OCT features of a ruptured plaque.

Keywords: Coronary artery disease, myocardial infarction, myocardial infarction with nonobstructive coronary arteries, optical coherence tomography, plaque rupture, ST elevation myocardial infarction


How to cite this article:
Subbramaniyam S, Sheel D, Yousif N, Noor HA, Shivappa S, Abdulrahman S. Myocardial infarction with non-obstructive coronary arteries: To stent or not to stent? That is the question. Heart Views 2021;22:293-6

How to cite this URL:
Subbramaniyam S, Sheel D, Yousif N, Noor HA, Shivappa S, Abdulrahman S. Myocardial infarction with non-obstructive coronary arteries: To stent or not to stent? That is the question. Heart Views [serial online] 2021 [cited 2022 May 28];22:293-6. Available from: https://www.heartviews.org/text.asp?2021/22/4/293/337542




   Introduction Top


MINOCA is defined as an acute myocardial infarction with nonobstructive coronary arteries on invasive coronary angiogram (i.e., no coronary stenosis >50% in any infarct-related artery) in the absence of a specific cause for acute presentation.[1] Numerous phrases are used to describe patients presenting with ACS and normal or near-normal coronary artery, such as MINOCA, MI in normal coronary artery, ischemia and no obstructive coronary artery disease, troponin-positive nonobstructive coronary artery disease, and ACS with normal or near-normal coronary arteries.[2]

Pasupathy et al. revealed that the prevalence of MINOCA in patients presenting with ACS is 6%. The percentage is higher in young patients, females, nonwhite patients, and patients presenting with non-ST elevation myocardial infarction (STEMI).[3] The “Variation in recovery: Role of gender on outcomes of young AMI patients study'' revealed that women are five times more likely to have MINOCA than men. It is usually associated with unconventional risk factors such as prior drug use, hypercoagulable syndrome, venous thromboembolism, and autoimmune disorders, rather than traditional risk factors such as hyperlipidemia, hypertension, and diabetes mellitus.[4]

Here, we present a case of MINOCA that underwent stenting of proximal left anterior descending (LAD) in the setting of extensive anterior wall STEMI in view of high-risk clinical presentation and optical coherence tomography (OCT) features of a ruptured plaque.


   Case Presentation Top


A 35-year-old Bahraini gentleman, smoker with no other known risk factors, was transferred to our cardiac center for rescue percutaneous coronary intervention (PCI) of failed lysis acute anterior wall STEMI [Figure 1]a and [Figure 1]b. Emergency coronary angiogram revealed haziness at the proximal LAD [Figure 2]a and otherwise no significant obstructive disease. OCT pullback was performed to study the morphological characteristics of the atheromatous plaque, pathogenesis of ACS, and risk stratification of MINOCA and to have an informed decision whether to deploy a stent or defer stenting.
Figure 1: (a) ST elevation myocardial infarction diagnosis at nonpercutaneous coronary intervention centre. (b) ECG at 60 min postfibrinolysis with ongoing chest pain, suggestive of failed lysis

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Figure 2: (a) Emergency coronary angiogram revealed haziness at the proximal left anterior descending. (b) Optical coherence tomography revealed plaque rupture at the proximal left anterior descending (5 o'clock) as culprit lesion with disruption of a thin fibrous cap that overlies a necrotic core and large cavity formation

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OCT revealed plaque rupture at the proximal LAD with disruption of a thin fibrous cap that overlies a necrotic core with large cavity formation [Figure 2]b, causing the thrombogenic contents of the necrotic core to come into contact with the bloodstream and, hence, significantly increase the risk of thrombus formation. In view of unstable, vulnerable plaque at the proximal LAD that carries a high risk of undergoing acute thrombosis and abrupt vessel occlusion, the consensus decision was not to take chances. Thus, we stented the proximal LAD with Xience Sierra 4.0 mm × 24 mm drug-eluting stent with excellent final angiographic result [Figure 3]a, which was confirmed by OCT [Figure 3]b. The patient had an uneventful hospital stay thereafter.
Figure 3: (a) Excellent final angiographic result (b) optical coherence tomography showed good stent apposition and stabilization of the thrombotic plaque (white arrow) by compression and axial redistribution away from the center. This modification of plaque geometry is crucial to seal the intimal tear and enhance healing

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   Discussion Top


The management of MINOCA depends on the underlying mechanism. Once the underlying cause is established, the working diagnosis of MINOCA should be discarded, and appropriate treatment related to the underlying condition should be initiated. In a catheterization laboratory, ventriculography can be performed to rule out takotsubo cardiomyopathy. Re-evaluation of patients through their medical history, physical examination, and lab assessment should be performed to exclude various causes of type 2 MI, pulmonary embolism, and nonischemic causes of myocyte injury such as myocarditis.[5] Spontaneous coronary artery dissection is one of the most important diagnoses to be excluded as these patients also do not present with traditional risk factors.[5],[6]

A raptured plaque may not be visible on conventional angiography. Hence, it is important that advanced intracoronary imaging techniques are employed to establish the characteristics of coronary disruption. The preferred mode of imaging is OCT as it provides accurate detection of plaque rupture and differentiates it from plaque erosion and calcified nodule.[7]

MINOCA patients with plaque erosion or calcified nodule should be treated with cardioprotective therapies such as antiplatelet, beta-blockers, ACE inhibitors, and lipid-lowering therapies. However, the finding of plaque rupture on OCT was associated with major adverse cardiac events with more than 2% risk of recurrent myocardial infarction or death up to 12 months. Hence, in patients with plaque rupture, PCI is the recommended strategy as the pathology is distinct, and the probability of major adverse events is much higher compared with plaque erosion and calcified nodule.[8],[9]


   Conclusion Top


Identification of plaque characteristics has potential therapeutic implications, and hence, intravascular imaging during coronary angiography of MINOCA is imperative and highly recommended.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his/her consent for images and other clinical information to be reported in the journal. The patient understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol 2018;72:2231-64.  Back to cited text no. 1
    
2.
Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio AL, et al. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J 2017;38:143-53.  Back to cited text no. 2
    
3.
Pasupathy S, Air T, Dreyer RP, Tavella R, Beltrame JF. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Circulation 2015;131:861-70.  Back to cited text no. 3
    
4.
Safdar B, Spatz ES, Dreyer RP, Beltrame JF, Lichtman JH, Spertus JA, et al. Presentation, clinical profile, and prognosis of young patients with myocardial infarction with nonobstructive coronary arteries (MINOCA): Results from the VIRGO study. J Am Heart Assoc 2018;7:e009174.  Back to cited text no. 4
    
5.
Barr PR, Harrison W, Smyth D, Flynn C, Lee M, Kerr AJ. Myocardial infarction without obstructive coronary artery disease is not a benign condition (ANZACS-QI 10). Heart Lung Circ 2018;27:165-74.  Back to cited text no. 5
    
6.
Pustjens TF, Appelman Y, Damman P, Ten Berg JM, Jukema JW, de Winter RJ, et al. Guidelines for the management of myocardial infarction/injury with non-obstructive coronary arteries (MINOCA): A position paper from the Dutch ACS working group. Neth Heart J 2020;28:116-30.  Back to cited text no. 6
    
7.
Farb A, Burke AP, Tang AL, Liang TY, Mannan P, Smialek J, et al. Coronary plaque erosion without rupture into a lipid core. A frequent cause of coronary thrombosis in sudden coronary death. Circulation 1996;93:1354-63.  Back to cited text no. 7
    
8.
Kramer MC, Rittersma SZ, de Winter RJ, Ladich ER, Fowler DR, Liang YH, et al. Relationship of thrombus healing to underlying plaque morphology in sudden coronary death. J Am Coll Cardiol 2010;55:122-32.  Back to cited text no. 8
    
9.
Leopoulou M, Mistakidi VC, Oikonomou E, Latsios G, Pa paioannou S, Deftereos S, et al. Acute coronary syndrome with non-ruptured plaques (NONRUPLA): Novel ideas and perspectives. Cu rr Atheroscler Rep 2020;22:21.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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