| Abstrakt: |
There are numerous clinical conditions in which symptoms and signs may overlap, among these myocardial Ischemia in the absence of obstructive coronaropathy (INOCA/MINOCA), gets into differential diagnosis with a plethora of clinical pictures such as Takotsubo syndrome, myocarditis and cardiomyopathies. In this setting, cardiac magnetic resonance has a critical discriminating role. Herein we report the clinical case of a 52–year old patient suffering from hypertension and dyslipidaemia, with a history of chest pain episodes and recent intense psychophysical stress. After symptoms exacerbation, ambulance was called, loss of conscience was witnessed, observing ventricular fibrillation, subjected to prompt DC shock. Once in Emergency room, ECG showed ST–elevation in V1, V2 and AVR for which urgent coronary angiography was performed. It surprisingly resulted negative for epicardial coronary artery disease. Moderate left ventricular dysfunction (LVEF 45%) was found on 2D ultrasound along with apex akinesia, while mild elevation myocardial necrosis enzymes was seen at blood tests. The clinical picture characterized by female sex, history of psychophysical stress, by association of chest pain, ischemic type alterations of repolarization at ECG, akinesia of the apex and the concomitant slight elevation of myocardial necrosis enzymes in the absence of epicardial coronary lesions, highly suggested Tako–Tsubo Syndrome. In order to confirm the diagnosis, cardiac MRI was performed which, unexpectedly, showed the presence of oedema on T2–weighted STIR sequences at the level of the left ventricular apex, associated to same site transmural fibrosis at post–contrast imaging sequences, thus eliciting the hypothesis of a MINOCA. After a new retrosternal pain with transient ST–elevation in V1, a IVUS – guided new coronary angiography examination was performed, resulting intoIVA diffuse coronary spasm, reduced after intravenous nitrate administration. Final diagnosis was “MINOCA complicated by primary VF‘‘ and a subcutaneous AICD implant CMR imaging by virtue of its ability to provide information about cardiac structure and function and simultaneously, to define the characterization of tissues, together with the data of dynamic coronary spasm, proved to be essential in this case to establish the diagnosis, often misunderstood, of MINOCA, hence allowing to define the best therapeutic strategy. |
