Gue Ying X, Prasad Sanjay, Isenberg David, Gorog Diana A
Department of Cardiology, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.
Department of Postgraduate Medicine, University of Hertfordshire, Hertfordshire, UK.
Eur Heart J Case Rep. 2019 Jun 1;3(2). doi: 10.1093/ehjcr/ytz041.
Myocardial infarction is most commonly caused by thrombosis occurring on a background of coronary atherosclerosis, resulting in reduced coronary flow. Less often, myocardial infarction can occur in the absence of coronary disease. The pathomechanism of myocardial infarction in such patients is heterogeneous and more challenging to diagnose and treat. European Society of Cardiology published a position paper on myocardial infarction in patients with non-obstructive coronary disease, with definitions and recommendations for investigations, in what has hitherto been an under-recognized and under-investigated Cinderella-like condition. However, the importance of obtaining a diagnosis is all the more important, since one treatment approach with revascularization and antithrombotic treatment does not 'fit all'.
A 70-year-old male patient presented with chest pain at rest, associated with rise in troponin and without ECG changes. A diagnosis of non-ST elevation myocardial infarction was made. Coronary angiography showed a smooth stenosis which resolved with administration of intracoronary nitrate. A diagnosis of coronary artery spasm was made, and treatment initiated. After 18 months, the patient had recurrent chest pains at rest, unresponsive to glyceryl trinitrate (GTN). Cardiac magnetic resonance revealed extension of subendocardial infarction, without inducible ischaemia. CT coronary angiogram (CTCA) showed non-obstructive coronaries. Blood tests showed significant eosinophilia, raised troponin, and C-reactive protein (CRP) that fluctuated without correlation with symptoms or any ECG changes. A diagnosis of Churg-Strauss syndrome was made, and immunosuppression commenced.
Churg-Strauss syndrome is an autoimmune vasculitis in patients with history of atopy or late-onset asthma which when involving coronary arteries can lead to myocardial injury mimicking acute coronary syndrome (ACS). Identification is important to allow initiation of immunosuppression which can prevent development or progression.
心肌梗死最常见的原因是在冠状动脉粥样硬化的基础上发生血栓形成，导致冠状动脉血流减少。较少见的情况下，心肌梗死可在无冠状动脉疾病时发生。此类患者心肌梗死的发病机制具有异质性，诊断和治疗更具挑战性。欧洲心脏病学会发表了一篇关于非阻塞性冠状动脉疾病患者心肌梗死的立场文件，给出了相关定义及检查建议，这是一种迄今未得到充分认识和研究的灰姑娘般的疾病状态。然而，做出诊断却尤为重要，因为一种血管重建和抗血栓治疗的方法并不适用于所有情况。
一名70岁男性患者出现静息性胸痛，肌钙蛋白升高且心电图无变化。诊断为非ST段抬高型心肌梗死。冠状动脉造影显示一处光滑狭窄，冠状动脉内注射硝酸酯后狭窄缓解。诊断为冠状动脉痉挛并开始治疗。18个月后，患者再次出现静息性胸痛，对硝酸甘油（GTN）无反应。心脏磁共振显示心内膜下梗死范围扩大，无诱发性缺血。CT冠状动脉造影（CTCA）显示冠状动脉无阻塞。血液检查显示显著嗜酸性粒细胞增多、肌钙蛋白升高以及C反应蛋白（CRP）波动，与症状或任何心电图变化均无相关性。诊断为变应性肉芽肿性血管炎并开始免疫抑制治疗。
变应性肉芽肿性血管炎是一种发生于有特应性病史或迟发性哮喘患者的自身免疫性血管炎，当累及冠状动脉时可导致类似急性冠状动脉综合征（ACS）的心肌损伤。识别该病很重要，以便开始免疫抑制治疗，从而预防疾病发展或进展。
