A normal coronary angiography … really?
Nicolas Amabile & Christophe Caussin
Institut Mutualiste Montsouris, Paris
- A 65 year-old man was referred for transient ST elevation MI.
- Medical history:
- Thrombophilia (FV Leiden)
- CV risk factors: Mild dyslipidemia
The per-critical EKG depicted a transient ST elevation in the apical leads (Fig 1) with normalization after isosorbide dinitrates ingestion (Fig 2)
Figure 2 – Click to enlarge
There was no recurrent chest pain after admission
A mild troponin rise up to 2.41 IU was measured
The initial management included anticoagulation with LMWH + double antiplatelet therapy ( clopidogrel 600 mg loading dose + aspirin)
A prompt coronary angiography was performed within the first 24h.
Coronary angiography views are provided
LAD analysis by OCT was performed.
The vessel presented a mild atherosclerotic infiltration with lipid-rich plaque and a discrete aspect of plaque rupture (with no remnant thrombus) on proximal LAD
CT scan confirmed the presence of a discrete plaque on proximal LAD
Two limited myocardial infarction zones were visualized on apical and lateral LV walls by CT scan and MRI
- Transient STEMI related to acute proximal LAD reversible occlusion.
- Underlying atherosclerotic infiltration with lipid-rich plaque
- Proximal LAD lipid plaque rupture with thrombus embolization in 1st Dg and distal LAD.
- No visible thrombus
- Subsequent management included medical therapy with double antiplatelet therapy (aspirin+ clopidogrel) for at least 1 year