Abstract
Stenting the culprit lesion in patients presenting with acute coronary syndrome (ACS) is the standard of care. Although plaque rupture on an atheromatous lesion is the most common underlying pathology, other mechanisms can also result in ACS presentation; some of which can be managed without stenting. Here we describe a case that was managed conservatively, after evaluating plaque erosion as the underlying mechanism and lack of obstructive lesion. This case highlights the importance of intracoronary imaging to assess the underlying mechanism in patients presenting with acute coronary syndrome.
1
Introduction
In patients presenting with ACS, including ST elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI), stenting the culprit lesions results in improved outcomes . Thrombotic coronary obstruction/occlusion, a characteristic of ACS, occurs most commonly with rupture of fibrous cap on vulnerable atheromatous plaque, whereas other possible mechanisms are plaque erosion, calcified nodules or stent thrombosis. Coronary thrombosis due to plaque erosion is characterized by absent/disrupted endothelium over a proteoglycan-rich lesion. In patients with plaque erosion, it is usually the large thrombus burden that occludes the coronary artery, whereas the plaque itself is usually not obstructive.
2
Case report
A 54-year-old man with prior double-lung transplant and coronary artery bypass surgery (grafts to left coronary circulation only) presented with chest pain. Electrocardiogram demonstrated inferior STEMI. Coronary angiography demonstrated patent grafts to the left coronary circulation, but a severe stenosis in proximal right coronary artery (RCA) and another moderate lesion in mid-RCA ( Fig. 1 B ).
Although the lesion appeared severe, flow into the distal vessel was preserved. The lesions appeared dynamic and improved with time and intra-coronary nitroglycerine ( Fig. 1 B and D–E). Optical coherence tomography (OCT) demonstrated plaque erosion with micro-thrombi in two separate areas of RCA, at the sites of angiographic lesions ( Fig. 1 C and F). Coronary spasm was thought to be the primary mechanism, and local release of vasoconstrictors from activated platelets in thrombi may plausibly have exacerbated spasm further. In absence of underlying flow limiting atherosclerotic lesion, we decided not to stent the RCA, and opted for conservative management including dual antiplatelet therapy. The patient has remained asymptomatic for more than a year since discharge.
2
Case report
A 54-year-old man with prior double-lung transplant and coronary artery bypass surgery (grafts to left coronary circulation only) presented with chest pain. Electrocardiogram demonstrated inferior STEMI. Coronary angiography demonstrated patent grafts to the left coronary circulation, but a severe stenosis in proximal right coronary artery (RCA) and another moderate lesion in mid-RCA ( Fig. 1 B ).
Although the lesion appeared severe, flow into the distal vessel was preserved. The lesions appeared dynamic and improved with time and intra-coronary nitroglycerine ( Fig. 1 B and D–E). Optical coherence tomography (OCT) demonstrated plaque erosion with micro-thrombi in two separate areas of RCA, at the sites of angiographic lesions ( Fig. 1 C and F). Coronary spasm was thought to be the primary mechanism, and local release of vasoconstrictors from activated platelets in thrombi may plausibly have exacerbated spasm further. In absence of underlying flow limiting atherosclerotic lesion, we decided not to stent the RCA, and opted for conservative management including dual antiplatelet therapy. The patient has remained asymptomatic for more than a year since discharge.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
