Myocardial Infarction due to Intracoronary Thrombi without Significant Coronary Artery Disease in Systemic Lupus Erythematosus

doi:10.1378/chest.100.2.571

Chest

Volume 100, Issue 2, August 1991, Pages 571-572

https://doi.org/10.1378/chest.100.2.571 Get rights and content

Acute myocardial infarction is a potentially fatal complication of SLE. Reported mechanisms include atherosclerosis, arteritis and coronary arterial spasm. The following case report presents a fourth possible cause; intracoronary thrombus with angiographically normal coronary arteries in a patient with active lupus and AMI.

(Chest 1991; 100:571-72)

Section snippets

CASE REPORT

A 26-year-old black woman with a four-year history of SLE was admitted with a three-day history of abdominal discomfort and nausea, followed by pleuritic chest pain. There was no history of hypertension, hypercholesterolemia or Raynaud's phenomenon. Her current medications included prednisone, aspirin and indocin. She had not taken birth control pills. Cardiac examination disclosed no abnormalities.

Electrocardiography revealed diffuse ST segment elevation, suggestive of acute pericarditis.

DISCUSSION

The clinical and electrocardiographic findings were suggestive of lupus pericarditis. Focally positive technetium scans also have been seen in pericardial disease.⁴ Elevated cardiac enzymes have been seen in lupus myocarditis.⁵ While the thallium defect suggested infarction, decreased apical activity may be a normal finding. The echocardiographic findings were most specific. To our knowledge, segmental wall motion abnormalities have not been reported in lupus myocarditis.

Our patient had no

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Cited by (24)

Non-traditional risk factors and the risk of myocardial infarction in the young in the US population-based cohort
2020, IJC Heart and Vasculature
Citation Excerpt :
Common comorbidities associated with SLE include MI and may be observed in up to 16% of SLE patients [13]. In the absence of coronary atherosclerosis on coronary angiography, patients with SLE may be predisposed to MI via a mechanism of coronary artery thrombosis or embolization, or coronary arteritis [14–17]. Several studies have suggested that patients with SLE had higher adjusted risk of MI compared with non-SLE control [18].
Although most prevalent in elderly, myocardial infarction (MI) also affects younger adults. We sought to investigate baseline characteristics in young patients (<55 years) with MI using the National Inpatient Sample (NIS) database between 2004 and 2015. Multivariable logistic regression models were used to assess factors associated with acute myocardial infarction (AMI) in young patients. After multivariable analyses adjusted for age, sex, race, family history of atherosclerosis, body mass index (BMI), diabetes, hypertension, hyperlipidemia, chronic kidney disease, and current cigarette smoking; novel risk factors such as human immunodeficiency virus (HIV), systemic lupus erythematosus (SLE), and obstructive sleep apnea (OSA) were associated with a higher risk of developing an AMI in the young (adjusted OR for HIV 4.06; 95 CI 3.48–4.71, p < 0.001), (adjusted OR for SLE 2.12; 95 CI 1.89–2.39, p 0.04), and (adjusted OR for OSA 1.16; 95 CI 1.12–1.20, p < 0.001), respectively. Rheumatoid arthritis was associated with a lower risk of AMI (adjusted OR 0.83; 95 CI 0.76–0.89, p < 0.001). After multivariable analyses, cigarette smoking (adjusted OR 1.98; 95 CI 1.95–2.02, p < 0.001), obesity (adjusted OR 1.37; 95 CI 1.33–1.41, p = 0.003), hyperlipidemia (adjusted OR 1.07; 95 CI 1.04–1.08, p < 0.001) and a family history of CAD (adjusted OR 1.35; 95 CI 1.3–1.4, p < 0.001) were also associated with a higher risk of developing an AMI in the young. In conclusion, young patients with AMI have both traditional risk factors and non-traditional risk factors. In addition to traditional risk factors, close attention should be paid to emerging risk factors such as SLE, HIV and OSA.
Immunopathology of systemic lupus erythematosus
2015, Rheumatology: Sixth Edition
Spontaneous coronary artery dissection in a 27-year-old woman
2013, Journal of Emergency Medicine
Citation Excerpt :
Cardiac complications of SLE include pericarditis, myocarditis, endocarditis, and acute coronary syndromes (16). Acute coronary syndromes in patients with SLE may result from atherosclerosis, coronary artery vasculitis, coronary artery spasm, in situ thrombosis, or, as demonstrated by the patient we present, spontaneous coronary artery dissection (17). Four similar cases of SCAD in young patients with SLE have been described in the literature (1,18–20).
Spontaneous coronary artery dissection (SCAD) causes acute coronary syndromes or sudden death in young patients who are often lacking classic coronary disease risk factors. Systemic inflammatory and connective tissue diseases have been suggested as risk factors for SCAD.
To review the risk factors, diagnosis, and management of this uncommon but life-threatening disease.
We report a case of a 27-year-old woman with a history of an ill-defined inflammatory arthropathy who presented with an acute ST-elevation myocardial infarction. SCAD was diagnosed by coronary angiography. Percutaneous coronary intervention was attempted but was unsuccessful. The patient recovered uneventfully with medical management and was ultimately diagnosed with systemic lupus erythematosus.
SCAD is a rare but important cause of acute coronary syndromes and sudden death. It commonly occurs in young women. Although pregnancy is the most well-established risk factor, systemic inflammatory and connective tissue diseases have also been suggested as risk factors.
Thrombus in normal coronary arteries: Retrospective study and review of case reports
2011, Archives of Cardiovascular Diseases
Myocardial infarction is rarely caused by non-occlusive thrombus in angiographically normal coronary arteries. The cases reported in the literature are scarce and follow-up was usually short. The efficacy and tolerability of the exclusively medical treatment strategy used in most cases remain unknown.
To evaluate efficacy of medical treatment and long-term prognosis in these patients.
We retrospectively selected and analysed patients hospitalized in our centre between 1998 and 2008 for myocardial infarction caused by non-occlusive thrombus in angiographically normal coronary arteries (defined as stenosis < 30%), who were exclusively medically treated. A long-term follow-up was performed. A review of the literature regarding such cases was carried out.
Sixteen patients were identified; apart from smoking, they had few conventional cardiovascular risk factors. Two patients died in hospital. The 14 survivors were followed up for an average of 4.9 years and only one death (non-cardiac cause) and one stroke (related to supraventricular arrhythmia) occurred in this period. Medical treatment included the use of glycoprotein IIb/IIIa inhibitors in 75% of cases. The literature review revealed 36 similar cases due to multiple aetiologies–particularly coronary artery spasm and prothrombotic coagulopathies.
Patients with myocardial infarction secondary to non-occlusive thrombus in angiographically normal coronary arteries seem to have a good long-term prognosis after the acute phase when treated with an exclusively medical strategy. However, initial clinical presentation was often severe, leading to early in-hospital death.
Les infarctus du myocarde peuvent, rarement, être causés par des thrombus non occlusifs sur des coronaires angiographiquement normales. Les cas rapportés dans la littérature ont été rares et leur suivi souvent court. L’efficacité et la tolérance du traitement médical exclusif, utilisé dans la plupart des cas, restent inconnues.
Évaluer l’efficacité du traitement médical et le pronostic à long terme chez ces patients.
Nous avons rétrospectivement sélectionné et analysé les patients hospitalisés dans notre centre, entre 1998 et 2008, pour un infarctus du myocarde causé par un thrombus non occlusif sur coronaires angiographiquement normales définies par des sténoses inférieures ou égales à 30 % et traités exclusivement médicalement. Un suivi à long terme a été effectué. Une revue de la littérature sur les cas similaires a été réalisée.
Seize patients ont été identifiés et hormis le tabagisme, ils avaient peu de facteurs de risques cardiovasculaires conventionnels. Deux patients sont décédés à l’hôpital. Les 14 survivants ont été suivis pendant 4,9 ans en moyenne, un décès de cause non cardiaque et un accident vasculaire cérébral relatif à un trouble du rythme supraventriculaire ont eu lieu. Le traitement médical comprenait l’utilisation des inhibiteurs des GPIIb/IIIa dans 75 % des cas. La revue de la littérature a révélé 36 cas similaires aux étiologies multiples, en particulier le spasme coronaire et les coagulopathies prothrombotiques.
Les patients avec infarctus du myocarde secondaire à un thrombus non occlusif sur coronaires angiographiquement normales semblent avoir un excellent pronostic à long terme après la phase aiguë lorsqu’ils ont été traités exclusivement médicalement mais la présentation clinique initiale fut souvent sévère conduisant à des décès hospitaliers précoces.
Myocardial injury in critically ill patients: Relation to increased cardiac troponin I and hospital mortality
2005, Chest
Citation Excerpt :
Physiologic stresses can occur in the form of either increased myocardial oxygen demands3 (eg, fever, tachycardia) or decreased myocardial oxygen delivery (eg, anemia, hypotension, hypoxemia) resulting in cardiac dysfunction, cardiac injury, or both.26 This potential for an imbalance between oxygen supply and demand and the known propensity of critically ill patients to develop acute thrombosis may explain the increase in the risk of myocardial injury.272829 The previous published data5 on critically ill patients suggest an association between enhanced systemic oxygen delivery (achieved with the use of dobutamine) and increased mortality from cardiac events, which may be related to secondary myocardial injury.
To examine the relationship between myocardial injury, assessed by cardiac troponin I (cTnI) levels, and outcome in selected critically ill patients without acute coronary syndromes or cardiac dysfunction.
Prospective, observational study in the emergency ICU of a university teaching hospital.
Over a 6-month period, 217 consecutive patients admitted to the ICU were studied.
cTnI assays were performed in all patients on admission to the ICU. The incidence of myocardial injury, defined by cTnI level > 0.1 ng/mL, was 32% (69 of 217 patients). Overall mortality was 27% (58 of 217 patients). Patients with myocardial injury had a mortality rate of 51%, compared with only 16% mortality for those without myocardial injury (p < 0.001). The hospital mortality rate was highest among older patients (71 ± 14% vs 58.5 ± 20%, p < 0.0001) and patients with higher simplified acute physiology scale (SAPS) II score (62 ± 25% vs 37 ± 17%, p < 0.0001). Mechanical ventilation was associated with higher in-hospital death (50% vs 31%, for patients who died in the hospital vs those who were discharged alive; p = 0.03). Elevated blood levels of cTnI were found to be independently associated with hospital mortality, regardless of the presence of SAPS II score and mechanical ventilation, in the logistic regression analysis (odds ratio, 2.09; 95% confidence interval, 1.06 to 4.11; p = 0.01).
This study demonstrates the high frequency of myocardial injury (32%) in critically ill patients without acute coronary syndromes or cardiac dysfunction on admission to ICU. Myocardial injury is an independent determinant of hospital mortality. Assessment of myocardial injury on admission to ICU would make it possible to identify patients at increased risk of death.
Cardiovascular disease in systemic lupus erythematosus: Recent data on epidemiology, risk factors and prevention
2020, Current Vascular Pharmacology

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Chest

Selected ReportsMyocardial Infarction due to Intracoronary Thrombi without Significant Coronary Artery Disease in Systemic Lupus Erythematosus

Section snippets

CASE REPORT

DISCUSSION

Prog Cardiovasc Dis

Am Heart J

Chest

Selected Reports
Myocardial Infarction due to Intracoronary Thrombi without Significant Coronary Artery Disease in Systemic Lupus Erythematosus