The Importance of Defining the Coronary Anatomy in Suspected Myopericarditis: A Case Report

Abstract

BACKGROUND It is challenging to distinguish between acute coronary syndrome (ACS) and myocardial injury due to alternative causes (eg myopericarditis, coronary vasospasm, and pulmonary embolism), as they often share similar presentations, especially in young patients. Coronary computerized tomography angiography (CCTA) is increasingly recognized as a fast and safe diagnostic tool for rapid assessment of the coronary anatomy among patients with a low to intermediate cardiovascular risk profile and/or atypical chest pain. However, its utility among patients with possible ACS is still debated. CASE REPORT A 36-year-old man presented to our institution with intermittent pleuritic chest pain and malaise over the preceding 7 days. He was a smoker and his father had ACS at the age of 45 years. The patient had unspecific electrocardiographic changes and elevated troponin values. The initial transthoracic echocardiogram indicated a normal ejection fraction without any wall motion abnormalities. Presuming a very low chance of coronary artery disease due to his age and atypical symptoms, we ordered a CCTA, which identified a thrombotic lesion in the right coronary artery (RCA). An invasive coronary angiography, including an optical coherence tomography, confirmed the presence of a thrombotic lesion located at the level of the proximal RCA, which was consequently treated with 1 drug-eluting stent. CONCLUSIONS Physicians should always eliminate underlying coronary artery disease among patients with unclear myocardial injury, irrespective of a patient's presentation, age, and estimated cardiovascular risk. In this context, CCTA represents a safe and simple tool to rapidly assess the coronary anatomy, especially in younger patients.

Conflict of interest statement

Conflict of interest: M. Madanchi, G.M. Cioffi, and R. Kobza report no conflicts of interest. F. Cuculi has received consulting and speaker fees from SIS Medical (Frauenfeld, Switzerland) and Abbott Vascular (Illinois, USA). M. Bossard has received consulting and speaker fees from Amgen (Rotkreuz, Switzerland), AstraZeneca (Cambridge, UK), Bayer (Leverkusen, Germany), and Mundipharma (Basel, Switzerland)

Conflict of Interest

M. Madanchi, G.M. Cioffi, and R. Kobza report no conflicts of interest. F. Cuculi has received consulting and speaker fees from SIS Medical (Frauenfeld, Switzerland) and Abbott Vascular (Illinois, USA). M. Bossard has received consulting and speaker fees from Amgen (Rotkreuz, Switzerland), AstraZeneca (Cambridge, UK), Bayer (Leverkusen, Germany), and Mundipharma (Basel, Switzerland).

Figures

Figure 1.

Electrocardiogram at admission, demonstrating an ascending ST-elevation in the precordial leads.

Figure 2.

(A) Coronary computerized tomography angiography showing the proximal right coronary artery stenosis. (B) 3D reconstruction of the coronary computerized tomography angiography. The green arrows mark the stenotic segments.

Figure 3.

(A) Coronary angiography showing the proximal right coronary artery stenosis pre-percutaneous coronary intervention. (B) Coronary angiography of the right coronary artery post-percutaneous coronary intervention. The yellow arrows point to the stenotic lesions.

Figure 4.

Optical coherence tomography of the proximal right coronary artery at the level of the stenosis. The upper part of the figure depicts a cross-section of the vessel and the presence of the (red) thrombus. The lower part of the figure shows a longitudinal section of the lesion and its length (25.6 mm).