Cardiogenic shock from acute myocardial infarction induced by large-vessel Arteritis
Yanping Liu1, Panpan Hao2 1 Shenzhen Research Institute of Shandong University, Shenzhen, Guangdong; Department of Radiology, Shandong University Qilu Hospital, Jinan, Shandong, China 2 Shenzhen Research Institute of Shandong University, Shenzhen, Guangdong; Department of Cardiology, Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Shandong University Qilu Hospital, Jinan, Shandong, China
Date of Web Publication
Correspondence Address: Panpan Hao Department of Cardiology, Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Shandong University Qilu Hospital, Jinan 250012, Shandong China
Source of Support: None, Conflict of Interest: None
Coronary artery involvement in large-vessel arteritis is not uncommon, but rarely fatal. Here, we present a case of a young female with arteritis who was admitted to our hospital with acute myocardial infarction-induced cardiogenic shock. Imaging and laboratory results demonstrate that anticardiolipin antibody-related large-vessel arteritis is a possible cause of coronary ostial stenosis in patients with no other risk factors.
Keywords: Anticardiolipin antibody, arteritis, large vessel, myocardial infarction, ostial stenosis
How to cite this article: Liu Y, Hao P. Cardiogenic shock from acute myocardial infarction induced by large-vessel Arteritis. Heart Mind 2018;2:57-9
Large-vessel arteritis is characterized by inflammation due to invasion of the arterial wall by leukocytes. Coronary artery involvement in this disease is not uncommon, but rarely fatal. Herein, we present a case of a young female with large-vessel arteritis who was admitted to our hospital with acute myocardial infarction (AMI)-induced cardiogenic shock.
A 23-year-old Chinese woman without medical history was brought to the emergency room after acute chest pain and palpitation developed at rest. Her systolic blood pressure on hospital admission was 69 mmHg. Cardiothoracic examination revealed bilateral fine rales. A 12-lead electrocardiogram showed sinus tachycardia, ST-segment elevation in lead aVR, and ST-segment depression in leads I, II, III, aVF, and V2 through V6 [Figure 1]a. Serum concentration of cardiac troponin I was 0.98 ng/mL. Initial assessment of the patient suggested the possibility of cardiogenic shock from AMI. Because of the profound hemodynamic instability, she was immediately transferred for cardiac catheterization. Urgent coronary angiography revealed isolated bilateral coronary ostial stenoses without thrombus [Figure 1]b and [Figure 1]c. An intra-aortic balloon pump was used to provide hemodynamic support, and then, a stent was deployed at the ostium of the left main coronary artery [Figure 1]d and the right coronary artery [Figure 1]e, respectively.
Figure 1: (a) Urgent 12-lead electrocardiogram. (b) Urgent angiography for the left main coronary, the left anterior descending artery, and the left circumflex artery. (c) Urgent angiography for the right coronary artery. (d) Angiography for the left main coronary, the left anterior descending artery, and the left circumflex artery after stenting. (e) Angiography for the right coronary artery after stenting
Computed tomography (CT) arteriography revealed no obvious abnormalities of the main arteries of the thorax and abdomen [Video 1]. Serum anticardiolipin immunoglobulin G (IgG) and IgM antibodies were moderately elevated. Anticardiolipin IgG was at a concentration of 31 IgG phospholipid units (<14 is considered negative), and IgM was at a concentration of 36 IgM phospholipid units (<12 is considered negative). However, levels of other autoimmune biomarkers were within normal ranges, including high-sensitivity C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), antineutrophil cytoplasmic antibodies, antinuclear antibodies, anti-double-stranded DNA, lupus anticoagulants, and anti-beta 2 glycoprotein 1 antibodies. She was discharged home on a regimen of aspirin, clopidogrel, and prednisone. During a 3-year follow-up, no other autoimmune diseases or complications of antiphospholipid antibodies occurred in this patient.
Imaging and laboratory results demonstrate that anticardiolipin antibody-related large-vessel arteritis is a possible cause of coronary ostial stenosis in patients with no other risk factors. Large-vessel arteritis is frequent in younger females and is characterized by infiltration of the arterial wall by mononuclear cells and/or multinucleated giant cells, leading to concentric medial hyperplasia, fibrosis, stenosis, and/or even occlusion. Takayasu arteritis (TA), one chronic vessel inflammation predominantly involving the aorta and its main branches, is mostly seen in females in the second or third decade of life, whereas giant cell arteritis (GCA), which has a predilection for cranial vessels, almost exclusively strikes people over age 50 years.
In our present case, this female fell into cardiogenic shock and was rescued by the combination of intra-aortic balloon pump counterpulsation with reperfusion therapy. We ruled out other causes of the shock other than AMI at the trunk lesion. The early detection and diagnosis of large-vessel arteritis before progression to such a severe condition are important. Large-vessel arteritis is diagnosed according to clinical presentation, imaging, laboratory values, and arterial biopsy. Patients usually present with focal symptoms induced by end-organ ischemia related to the vessels affected by stenotic or occlusive lesions, as well as constitutional complaints, including fever, malaise, and anorexia. Both TA and GCA have been reported to involve the coronary arteries and aggravate atherosclerosis, and these patients tend to present with symptomatic myocardial ischemia.
Early diagnosis of large-vessel arteritis is difficult since it is a rare disease and is accompanied by various nonspecific clinical symptoms. However, recent advances in noninvasive imaging modalities, including magnetic resonance angiography, CT angiography, sonography, and fluorodeoxyglucose positron emission tomography (FDG-PET)/CT, have facilitated earlier and more accurate diagnoses of this condition. Arterial wall thickening with crescents and indistinct vascular borders are almost exclusively displayed in CT and magnetic resonance angiography. Coronary artery involvement is not uncommon and most frequently includes the ostia and proximal segment, as in our case. Sonography and FDG-PET/CT are useful in evaluating active inflammation in the arteries involved., As conventional invasive angiography has limited ability to detect arterial wall inflammation and remodeling, intracoronary imaging with intravascular ultrasound or optical coherence tomography might be required. ESR and CRP levels should be used for initial testing, with a sensitivity of 99% when taken in combination. Other autoimmune biomarkers may be nonspecific elevated as well. In line with our patient, ESR and CRP were normal in some case reports of arteritis patients; thus, treatment should not be withheld when a patient is under high clinical suspicion of this disease.
Given the high mortality rate associated with severe stenosis and occlusion, revascularization is recommended, but the procedure modality has a great impact on the prognosis. Surgical bypasses exhibit better outcomes than percutaneous interventions, which are frequently burdened with postoperative complications, including restenosis, stent detachment, new arterial lesions, and so on. Therefore, it is crucial that disease activity is controlled with adequate immunosuppressive treatments, regardless of revascularization or not. Finally, a long-term follow-up is mandatory for all these young patients.
Predicting outcome of patients with this disease is challenging due to the large variation in the course. The presence of a major complication and/or a progressive course might be indicators of poor prognosis. Recently, type V angiographic classification was identified as an independent predictive factor for disease activity. Nevertheless, data regarding long-term prognosis are lacking.
Coronary artery involvement in arteritis is not uncommon, but rarely fatal. Anticardiolipin antibody-related large-vessel arteritis is a possible cause of coronary ostial stenosis in patients with no other risk factors.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This work was supported by the Shenzhen Science and Technology Research and Development Fund (No. JCYJ20160331183804137) and the Planned Science and Technology Project of Guangdong Province (No. 2017A020215005).
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