Unusual clinical course, Challenging differential diagnosis
Mehdi Madanchi, Giacomo Maria Cioffi, Richard Kobza, Florim Cuculi, Matthias Bossard
Department of Cardiology, Herzzentrum, Luzerner Kantonsspital, Lucerne, Switzerland
Am J Case Rep 2021; 22:e929009
Available online: 2021-02-22
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.
Keywords: acute coronary syndrome, Coronary Angiography, Coronary Artery Disease, Myocardial Infarction, Pericarditis