88 Images in CAD
Images in CAD Coronary Artery Disease 2015, 26:88–90
Isolated coronary artery aneurysms presenting with ST-elevation myocardial infarction – a case of when less is more Kalpa De Silvaa and Michael Mahmoudia,b, aDepartment of Cardiology, St. Peter’s Hospital and bUniversity of Surrey, Surrey, UK Correspondence to Michael Mahmoudi, BSc, MBBS, MRCP, PhD, FACC, Department of Cardiology, St. Peter’s Hospital, Chertsey, Surrey, UK Tel: + 44 193 287 2000; e-mail: [email protected] Received 29 June 2014 Revised 7 July 2014 Accepted 8 July 2014
Introduction Coronary aneurysms are defined as a localized dilatation that can be saccular (transverse larger than the longitudinal axis) or fusiform (longitudinal at least twice the transverse axis). This is a distinct entity from coronary artery ectasia, in which there is diffuse dilatation involving greater than half of the coronary artery. Coronary artery aneurysm (CAA) formation has been described in the literature as early as 1761 by Morgagni [1]. The incidence of CAAs reported in different observational series ranges from 0.9 to 4.9% [2,3]. However, the management of patients presenting with acute myocardial infarction (AMI) in this setting remains a quandary and is subject to limited clinical evidence. This case provides a further anecdote in the management of aneurysm-related AMI.
Case report A 57-year-old lady presented to our hospital with cardiac chest pain at rest for the preceding 4 h. Her ECG showed ST-segment elevation and q-waves in the inferior leads (Fig. 1). In view of her continuing pain, emergency angiography was performed and showed aneurysmal left and right coronary systems, with the infarct-related artery being a large aneurysmal right coronary artery (RCA) with significant thrombus burden, and TIMI-1 antegrade flow (Fig. 2). Percutaneous revascularization was not undertaken in view of the anatomical nature of the RCA, and the patient was therefore managed medically. Echocardiography showed severe hypokinesis of the inferior lateral wall, thrombus within the RCA, and an ejection fraction of 40% (Fig. 3). Haematological and biochemical assessments were negative for autoimmune or systemic disorders. A computed tomography angiogram, performed to determine whether there was evidence of widespread vascular aneurysm formation, reaffirmed aneurysmal coronary arteries but no other regions of aneurysm formation (Fig. 4). The patient was prescribed with 12 months of clopidogrel, lifelong warfarin bridged with low molecular weight heparin, in addition to β-blocker, angiotensinconverting-enzyme inhibitor, high-dose statin and aldosterone antagonist therapy. She remains well 12 months after her index event, with no angina and no
Fig. 1
ECG – inferior ST elevation. 0954-6928 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
DOI: 10.1097/MCA.0000000000000163
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Isolated coronary artery aneurysms with STEMI De Silva and Mahmoudi 89
Fig. 2
(a) Left coronary system showing the aneurysmal left main stem. (b) Right coronary artery with a mid-distal vessel occlusion (black arrow) with TIMI-1 antegrade flow (grey arrow).
Fig. 3
V
V 5
10 10
15
20
Echocardiogram showing aneurysmal dilatation of the right coronary artery with intraluminal thrombus (white arrows).
significant heart failure symptoms (NYHA class 1). A follow-up echocardiogram has shown mild inferior hypokinesis with an ejection fraction of 45–50%.
Discussion Coronary artery aneurysms are rare but remain a substrate for AMI, with ∼ 30–50% of patients with aneurysm formation
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
90 Coronary Artery Disease 2015, Vol 26 No 1
Fig. 4
presenting in this context. Observational data suggest that there is an association with atherosclerosis; however, AMI can occur in the absence of a significant coronary stenosis, with Daoud et al. [4] identifying a degree thrombus present in 70% of patients with coronary aneurysms during postmortem examination. In concordance with these findings, Swanton and colleagues [5] subsequently demonstrated the presence of reduced coronary blood flow in patients with coronary aneurysms, which may be a potential nidus for clot formation and subsequent thrombotic vessel occlusion. Latterly, an observational study by Baman et al. [3] identified patients with CAA as having an increased mortality, independent of the presence of coronary artery disease, which is likely to reaffirm the pathophysiological connection with increased thrombus formation in those with CAAs. Although further evidence is required to increase the understanding of how these subsets of patients should be optimally managed, this case highlights the potential role of formal anticoagulation in the management of patients presenting with an acute coronary syndrome. Conclusion
Conservative management with anticoagulation for a thrombotic occlusion of an aneurysmal coronary artery presenting with AMI is an acceptable and safe mode of management rather than routine mechanical revascularization.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2 3
Computed tomography images. (a) Transverse plane view of a thrombus-laden (dotted white arrows) aneurysmal right coronary artery. (b) Three-dimensional reconstruction showing no other aneurysmal portions of the vascular tree.
4 5
Robinson FC. Aneurysms of the coronary arteries. Am Heart J 1985; 109:129–135. Swaye PS, Fisher LD, Litwin P, Vignola PA, Judkins MP, Kemp HG, et al. Aneurysmal coronary artery disease. Circulation 1983; 67:134–138. Baman TS, Cole JH, Devireddy CM, Sperling LS. Risk factors and outcomes in patients with coronary artery aneurysms. Am J Cardiol 2004; 93:1549–1551. Daoud AS, Pankin D, Tulgan H, Florentin RA. Aneurysms of the coronary artery. Report of ten cases and review of literature. Am J Cardiol 1963; 11:228–237. Swanton RH, Thomas ML, Coltart DJ, Jenkins BS, Webb-Peploe MM, Williams BT. Coronary artery ectasia – a variant of occlusive coronary arteriosclerosis. Br Heart J 1978; 40:393–400.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Images in CAD Coronary Artery Disease 2015, 26:88–90
Isolated coronary artery aneurysms presenting with ST-elevation myocardial infarction – a case of when less is more Kalpa De Silvaa and Michael Mahmoudia,b, aDepartment of Cardiology, St. Peter’s Hospital and bUniversity of Surrey, Surrey, UK Correspondence to Michael Mahmoudi, BSc, MBBS, MRCP, PhD, FACC, Department of Cardiology, St. Peter’s Hospital, Chertsey, Surrey, UK Tel: + 44 193 287 2000; e-mail: [email protected] Received 29 June 2014 Revised 7 July 2014 Accepted 8 July 2014
Introduction Coronary aneurysms are defined as a localized dilatation that can be saccular (transverse larger than the longitudinal axis) or fusiform (longitudinal at least twice the transverse axis). This is a distinct entity from coronary artery ectasia, in which there is diffuse dilatation involving greater than half of the coronary artery. Coronary artery aneurysm (CAA) formation has been described in the literature as early as 1761 by Morgagni [1]. The incidence of CAAs reported in different observational series ranges from 0.9 to 4.9% [2,3]. However, the management of patients presenting with acute myocardial infarction (AMI) in this setting remains a quandary and is subject to limited clinical evidence. This case provides a further anecdote in the management of aneurysm-related AMI.
Case report A 57-year-old lady presented to our hospital with cardiac chest pain at rest for the preceding 4 h. Her ECG showed ST-segment elevation and q-waves in the inferior leads (Fig. 1). In view of her continuing pain, emergency angiography was performed and showed aneurysmal left and right coronary systems, with the infarct-related artery being a large aneurysmal right coronary artery (RCA) with significant thrombus burden, and TIMI-1 antegrade flow (Fig. 2). Percutaneous revascularization was not undertaken in view of the anatomical nature of the RCA, and the patient was therefore managed medically. Echocardiography showed severe hypokinesis of the inferior lateral wall, thrombus within the RCA, and an ejection fraction of 40% (Fig. 3). Haematological and biochemical assessments were negative for autoimmune or systemic disorders. A computed tomography angiogram, performed to determine whether there was evidence of widespread vascular aneurysm formation, reaffirmed aneurysmal coronary arteries but no other regions of aneurysm formation (Fig. 4). The patient was prescribed with 12 months of clopidogrel, lifelong warfarin bridged with low molecular weight heparin, in addition to β-blocker, angiotensinconverting-enzyme inhibitor, high-dose statin and aldosterone antagonist therapy. She remains well 12 months after her index event, with no angina and no
Fig. 1
ECG – inferior ST elevation. 0954-6928 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
DOI: 10.1097/MCA.0000000000000163
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Isolated coronary artery aneurysms with STEMI De Silva and Mahmoudi 89
Fig. 2
(a) Left coronary system showing the aneurysmal left main stem. (b) Right coronary artery with a mid-distal vessel occlusion (black arrow) with TIMI-1 antegrade flow (grey arrow).
Fig. 3
V
V 5
10 10
15
20
Echocardiogram showing aneurysmal dilatation of the right coronary artery with intraluminal thrombus (white arrows).
significant heart failure symptoms (NYHA class 1). A follow-up echocardiogram has shown mild inferior hypokinesis with an ejection fraction of 45–50%.
Discussion Coronary artery aneurysms are rare but remain a substrate for AMI, with ∼ 30–50% of patients with aneurysm formation
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
90 Coronary Artery Disease 2015, Vol 26 No 1
Fig. 4
presenting in this context. Observational data suggest that there is an association with atherosclerosis; however, AMI can occur in the absence of a significant coronary stenosis, with Daoud et al. [4] identifying a degree thrombus present in 70% of patients with coronary aneurysms during postmortem examination. In concordance with these findings, Swanton and colleagues [5] subsequently demonstrated the presence of reduced coronary blood flow in patients with coronary aneurysms, which may be a potential nidus for clot formation and subsequent thrombotic vessel occlusion. Latterly, an observational study by Baman et al. [3] identified patients with CAA as having an increased mortality, independent of the presence of coronary artery disease, which is likely to reaffirm the pathophysiological connection with increased thrombus formation in those with CAAs. Although further evidence is required to increase the understanding of how these subsets of patients should be optimally managed, this case highlights the potential role of formal anticoagulation in the management of patients presenting with an acute coronary syndrome. Conclusion
Conservative management with anticoagulation for a thrombotic occlusion of an aneurysmal coronary artery presenting with AMI is an acceptable and safe mode of management rather than routine mechanical revascularization.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2 3
Computed tomography images. (a) Transverse plane view of a thrombus-laden (dotted white arrows) aneurysmal right coronary artery. (b) Three-dimensional reconstruction showing no other aneurysmal portions of the vascular tree.
4 5
Robinson FC. Aneurysms of the coronary arteries. Am Heart J 1985; 109:129–135. Swaye PS, Fisher LD, Litwin P, Vignola PA, Judkins MP, Kemp HG, et al. Aneurysmal coronary artery disease. Circulation 1983; 67:134–138. Baman TS, Cole JH, Devireddy CM, Sperling LS. Risk factors and outcomes in patients with coronary artery aneurysms. Am J Cardiol 2004; 93:1549–1551. Daoud AS, Pankin D, Tulgan H, Florentin RA. Aneurysms of the coronary artery. Report of ten cases and review of literature. Am J Cardiol 1963; 11:228–237. Swanton RH, Thomas ML, Coltart DJ, Jenkins BS, Webb-Peploe MM, Williams BT. Coronary artery ectasia – a variant of occlusive coronary arteriosclerosis. Br Heart J 1978; 40:393–400.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
