Morooka Masaki, Kurihara Osamu, Takano Masamichi, Miyauchi Yasushi
Cardiovascular Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamakari, Inzai, Chiba 270-1694, Japan.
Eur Heart J Case Rep. 2023 Apr 28;7(5):ytad225. doi: 10.1093/ehjcr/ytad225. eCollection 2023 May.
Diagnostic strategies depend on non-standardized workup, and the causes of myocardial infarction with non-obstructive coronary arteries remain unclear for some patients. Intracoronary imaging is recommended for detecting the missed causes by coronary angiography. Myocardial infarction with non-obstructive coronary arteries is a heterogeneous entity; a meta-analysis of myocardial infarction with non-obstructive coronary artery studies demonstrated that all-cause mortality rate at 1 year is 4.7%, and its prognosis is not so favourable.
A 62-year-old man without remarkable medical history complained of acute chest pain at rest, which resolved at his arrival. Although echocardiography and electrocardiogram exhibited normal findings, the concentration of high-sensitive cardiac troponin T increased up to 0.384 from 0.04 ng/mL. Coronary angiography was performed, and mild stenosis of the proximal right coronary artery was detected. He was discharged without catheter intervention and medications as he reported no symptoms. He returned 8 days later because of inferoposterior ST-segment elevation myocardial infarction with ventricular fibrillation. Emergent coronary angiography showed that the mild stenosis of the proximal right coronary artery had progressed to total occlusion. Optical coherence tomography after thrombectomy revealed rupture of the thin-cap fibroatheroma and protruding thrombus.
Patients presenting with myocardial infarction with non-obstructive coronary arteries and plaque disruption and/or thrombus detected by optical coherence tomography do not show normal coronaries on coronary angiography. Aggressive investigation into plaque disruption using intracoronary imaging is recommended even if coronary angiography demonstrates mild stenosis to prevent a fatal attack for suspicious cases of myocardial infarction with non-obstructive coronary arteries.
诊断策略依赖于非标准化检查，对于一些患者，非阻塞性冠状动脉所致心肌梗死的病因仍不明确。推荐采用冠状动脉内成像来检测冠状动脉造影遗漏的病因。非阻塞性冠状动脉所致心肌梗死是一种异质性疾病；一项对非阻塞性冠状动脉研究的荟萃分析表明，1年全因死亡率为4.7%，其预后并不理想。
一名62岁男性，无显著病史，主诉静息时急性胸痛，到达时胸痛缓解。尽管超声心动图和心电图检查结果正常，但高敏心肌肌钙蛋白T浓度从0.04 ng/mL升至0.384。进行了冠状动脉造影，发现右冠状动脉近端轻度狭窄。由于他报告无症状，未进行导管干预及用药便出院。8天后，他因下后壁ST段抬高型心肌梗死伴心室颤动再次入院。急诊冠状动脉造影显示，右冠状动脉近端的轻度狭窄已进展为完全闭塞。血栓切除术后的光学相干断层扫描显示薄帽纤维粥样斑块破裂并伴有突出血栓。
对于非阻塞性冠状动脉所致心肌梗死且经光学相干断层扫描检测到斑块破裂和/或血栓形成的患者，冠状动脉造影显示冠状动脉并非正常。即使冠状动脉造影显示轻度狭窄，对于可疑的非阻塞性冠状动脉所致心肌梗死病例，建议采用冠状动脉内成像对斑块破裂进行积极检查，以预防致命发作。
