Download ST-elevation acute myocardial infarction due to

ST-elevation acute myocardial infarction due to arterial
thrombosis in a 29-year-old woman with normal coronary
arteries
Eneida Male, MD, Talitha Morton, DO, Adam Farber, MD, and Jeffrey Michel, MD
Acute myocardial infarction (AMI) is rare in young adults. We present a
case of a 29-year-old black woman who presented with an acute onset of
chest pain while sleeping. Anterior wall ST-elevation AMI was diagnosed
based on clinical presentation, electrocardiographic findings, and elevated
cardiac biomarkers. Coronary angiography revealed a totally occluded
proximal left anterior descending artery. The obstructing lesion, thrombus, was removed. There was no evidence of atherosclerotic disease or
dissection. An evaluation for a hypercoagulable state was unrevealing.
Echocardiography 1 year later revealed normal left ventricular wall motion
and systolic function.
W
e report the case of acute coronary thrombosis in a
29-year-old woman without significant risk factors
for coronary artery disease.
CASE REPORT
A healthy, 29-year-old black woman presented to the emergency department with substernal chest pain that awoke her
from sleep approximately 30 minutes prior to arrival. The
pain radiated to her left arm and was also associated with
dyspnea. Ibuprofen did not alleviate her pain. She smoked 20
cigarettes a day for 5 years. She also used natural and synthetic
marijuana, but not over the past 2 years. She had a body mass
index of 28 kg/m2, had no previous medical problems or prior
surgery, and was not taking any medications. She had seven
living children from six uncomplicated pregnancies, with the
last being 1 year earlier. Her mother had antiphospholipid
antibody syndrome. Chest radiograph was normal. Electrocardiogram revealed normal sinus rhythm with ST segment elevations in leads I, aVL, and V4 to V6 and ST segment depressions
in leads III and V1(Figure 1). A complete blood count and
comprehensive metabolic panel were unremarkable. Her initial
serum troponin level was 1.2 ng/mL, with a peak of 46.21
on serial measurement. Her total cholesterol was 122 mg/dL;
low-density lipoprotein, 69 mg/dL; high-density lipoprotein,
34 mg/dL; and triglycerides, 60 mg/dL. A urine drug screen
was negative for marijuana, cocaine, and amphetamines, and
her pregnancy test was negative. The patient was given aspirin
(325 mg), sublingual nitroglycerin (0.4 mg), and intravenous
Proc (Bayl Univ Med Cent) 2017;30(1):59–61
heparin (bolus 4000 units). Coronary angiography revealed an
occlusion in the left anterior descending artery (Figure 2). She
underwent thrombectomy using an AngioJet catheter system.
Intracoronary optical coherence tomography and intravascular
ultrasound revealed no plaque and no dissection. Percutaneous coronary intervention was not performed, and no stent
was placed.
Transthoracic echocardiogram revealed a left ventricular
ejection fraction of 30% with extensive anterior, anteroseptal, and apical wall motion abnormalities. Laboratory results
(Table 1) were normal with the exception of an elevated Creactive protein level. The patient was started on dual antiplatelet therapy with aspirin 81 mg daily and prasugrel 10 mg
daily. In addition, a high-intensity statin, oral beta-blocker, and
angiotensin-converting enzyme inhibitor were also initiated
per the 2013 American College of Cardiology Foundation/
American Heart Association guidelines for management of
ST-elevation myocardial infarction. Due to the occurrence of
acute coronary artery thrombosis of undetermined etiology,
anticoagulation with warfarin was also initiated, with a goal
international normalized ratio of 2 to 3. A temporary, wearable cardiac defibrillator was recommended at discharge due
to her significantly reduced left ventricular ejection fraction;
however, the patient declined the device. Additional recommendations included outpatient follow-up with the hematology/oncology clinic for continued evaluation of a possible
coagulation disorder, given the presence of antiphospholipid
antibody syndrome in a first-degree relative.
Our patient failed to take the prescribed medications
and to follow up with hematology/oncology, and she did not
undergo further testing. During a later hospitalization for
pregnancy, she underwent echocardiography that demonstrated normal left ventricular systolic function and normal
wall motion.
From the Cardiology Division, Baylor Scott and White Memorial Hospital, Temple,
Texas (Male, Morton, Farber, Michel); and Texas A&M University Health Science
Center College of Medicine, Temple, Texas (Michel).
Corresponding author: Jeffrey Michel, MD, FACC, Cardiology Division, Baylor
Scott and White Memorial Hospital, 2401 South 31st Street, Temple, TX 76508
(e-mail: [email protected]).
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Figure 1. Initial electrocardiogram showing normal sinus rhythm, ST segment elevation in leads I, aVL, and V4 to V6, and ST segment depressions in leads III and V1.
DISCUSSION
While acute coronary syndrome is prevalent in individuals
over 45 years of age, it is rare in those younger than 30 (1). AMI
with angiographically normal coronary arteries is an important
subgroup of AMI in young patients (1, 2). Some etiologies
reported include coronary artery anomalies, cocaine-induced
coronary artery vasospasm, a hypercoagulable state related to
a
the use of oral contraceptive pills, and diseases such as systemic
lupus erythematosus, antiphospholipid antibody syndrome,
Factor V Leiden mutation, and nephrotic syndrome (3–5). The
incidence of AMI in patients <45 years of age is estimated to be
2% to 10% of all AMIs (4–6). Although the incidence of AMI
related to a hypercoagulable state is unclear, it may comprise
approximately 5% of AMIs in young patients (4).
b
Figure 2. Coronary angiograms showing (a) acute left anterior descending artery thrombosis and (b) left anterior descending artery after thrombectomy.
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Baylor University Medical Center Proceedings
Volume 30, Number 1
Table 1. Laboratory studies evaluating for a hypercoagulable state
Laboratory test
Result
Normal values
Anti-nuclear antibody profile
Negative
Anti-cardiolipin IgG (GPL)
<9.4
<15
Anti-cardiolipin IgM (MPL)
<9.4
<12
Beta-2 glycoprotein I IgG (SGU)
12
<18
Beta-2 glycoprotein IgM (SMU)
<9.4
<18
C-reactive protein (mg/L)
7.3
0–3.2
Erythrocyte sedimentation rate (mm/h)
16
0–20
In our case, the only traditional coronary artery disease risk
factor was prior tobacco use, with only a 5-pack-year history.
Emergent coronary angiography revealed an acute left anterior
descending artery thrombus, without evidence of atherosclerotic coronary disease, coronary artery dissection, or anomaly.
Transthoracic echocardiogram showed no evidence of intracardiac thrombus, infective endocarditis, or valvular abnormality.
Although the patient did report a remote history of substance
abuse, her urine drug screen was negative for cocaine, amphetamines, and marijuana metabolites.
1.
Factor V Leiden mutation, C677T/A129BC Not detected
5.0–15.0
2.
Homocysteine, serum level (μmol/L)
4.7
Lupus anticoagulant panel
Not detected
MTHFR gene analysis
Negative
Protein C, total antigen (%)
77
63–153
4.
Protein C, functional (%)
97
83–168
5.
Protein S, activity (%)
76
57–131
Protein S, free antigen (%)
61
55–123
Prothrombin G20210A mutation
Not detected
3.
6.
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Thomas RH. Hypercoagulability syndromes. Arch Intern Med 2001;
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Choudhury L, Marsh JD. Myocardial infarction in young patients. Am J
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experience. Am Heart J 2002;143(1):56–62.
GPL indicates IgG phospholipid unit; MPL, IgM phospholipid unit; SGU, standard IgG
beta-2 glycoprotein unit; SMU, standard IgM beta-2 glycoprotein unit.
January 2017
ST-elevation acute myocardial infarction due to arterial thrombosis in a 29-year-old woman with normal coronary arteries
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