Plaque rupture in young with Rheumatoid Arthritis

#CardioTwitterCase originally published on Twitter

This case was originally published on Twitter by @CESARJERONIMOVS via #CardioTwitterCase

Clinical presentation

A 37-year-old female patient with a history of rheumatoid arthritis 3 years ago in management with Prednisone, NSAIDs and chloroquine. Does not use oral contraceptives, does not present stress. Admitted for acute myocardial infarction without ST elevation 2 days before. ECG with anteroseptal necrosis and complete blockage of the right branch. Troponin T > 50ng/mL

Figure 1. Initial Angiogram

Figure 1. Initial Angiogram

Case management

The patient was taken to the Cath lab and the angiogram showed extensive thrombus ostial and proximal of LAD, suboclusive that compromised the flow, distal TIMI II. Ventriculogram evidences severe anterolateral, apical, anterobasal and inferoapical hypokinesia, LVEF 37%. Circumflex artery and right coronary without lesions, without evidence of dissection, erosion or plaque rupture. It was decided to start GP IIb / IIIa antagonist (Tirofiban), continue dual antiplatelet, LMWH and keep it in CCU for a second angio in 48 hours. The patient evolves hemodynamically stable, without new episodes of angina and is taken back to CathLab at 72 hours. The control angio shows discreet decrease in ostial and proximal thrombotic load of LAD, improving distal TIMI III flow.

Figure 2. Angio control Post GP IIb / IIIa antagonist

Figure 2. Angio control Post GP IIb / IIIa antagonist

It is decided to perform IVUS (Eagle Eye Platinum RX Digital IVUS Catheter 40Hz - Volcano), which demonstrates the thrombus burden is larger than the plaque. The segment of the vessel wall with plaque is very short. Thus, a small plaque disruption triggered a large thrombotic response as the etiology of the ACS. It was decided to perform coronary angioplasty guided by IVUS. Two angioplasty guides 0.014" (Runthrough NS Floppy- Medtronic ) were advanced to LAD and another to the Circumflex and direct Resolute Onix (Medtronic) 3.5x28mm stent was implanted at 16 atm from LM to LAD (Provisional Stent) with POT 4.0x12mma 24 atm.

Figure 3. IVUS and PCI

Figure 3. IVUS and PCI

 
Final angiography with optimal result, no residual lesions, TIMI III flow and no compromise of bifurcation. IVUS post stent with adequate apposition and expansion of the stent. The patient progressed satisfactorily and was discharged after 5 days with dual antiplatelet treatment (Ticagrelor 90 mg BID PO, ASA 81 mg QD), lipid-lowering drugs and immunomodulators of rheumatoid arthritis.

This case demonstrates the importance of performing imaging studies such as IVUS / OCT in difficult scenarios that determine the etiology of acute coronary events and guide us in their management. We are impressed every day to see more coronary disease in young people.

Author

Cesar Villalobos

@CESARJERONIMOVS

Tunja, Colombia

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