A normal coronary angiography … really?

Nicolas Amabile & Christophe Caussin
Cardiology Department
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 1 – Click to enlarge

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

In Summary:

• 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 1^st Dg and distal LAD.
• No visible thrombus
• Subsequent management included medical therapy with double antiplatelet therapy (aspirin+ clopidogrel) for at least 1 year