Acute Perimyocarditis – an ST-Elevation Myocardial Infarction Mimicker: A Case Report
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BACKGROUND A normal coronary angiogram in ST-elevation myocardial infarction (STEMI) can be considered a myocardial infarction with non-obstructive coronary arteries (MINOCA) until an alternative diagnosis is obtained. However, the COVID-19 pandemic might delay urgent coronary angiography in a resource-limited setting. Perimyocarditis often causes symptoms, such as chest pain, as well as ST-elevation and high cardiac troponin levels. This STEMI mimicker can also cause cardiogenic shock and death when not treated properly. CASE REPORT A 40-year-old man reported having acute onset of substernal chest pain, which was suspected to be STEMI. The patient was an active smoker without any risk factors or a history of cardiovascular disease. The examination showed elevated cardiac troponin I, ST-elevation in high lateral leads, and regional wall motion abnormality (RWMA) by echocardiogram. Furthermore, thrombolytic therapy had failed, and rescue percutaneous coronary intervention was not performed due to the catheterization laboratory limitation during the COVID-19 pandemic. Before coronary angiography, the patient was scheduled for 2 consecutive days of COVID-19 polymerase chain reaction (PCR) swabs. On the second day of hospitalization, the patient experienced a cardiogenic shock. The COVID-19 PCR results were negative, while coronary angiography revealed normal coronary arteries. The patient was eventually diagnosed with probable acute perimyocarditis. CONCLUSIONS Myocarditis is implicated in young patients without typical cardiovascular risk factors or in those with recent infection and cardiovascular symptoms mimicking acute coronary syndrome. It might also be present in situations where ST-elevation distribution on the electrocardiogram is discordant with the RWMA observed on the echocardiogram.Keywords:
Cardiac catheterization
ST elevation
The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists, reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure.
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Cardiac catheterization
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Myocardial infarction complications
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Classically, cardiogenic shock has been considered a sequela of ST-segment elevation myocardial infarction, most commonly caused by left ventricular dysfunction resulting from ongoing ischemia and cell necrosis. In keeping with this scenario, most of the current literature on cardiogenic shock confines itself to ST-segment elevation. It must be remembered, however, that Herrick’s classic description of cardiogenic shock in 1912 predated the discovery and application of electrocardiography, emphasizing the important fact that in the setting of acute myocardial infarction, shock may occur irrespective of the direction of the electrocardiographic abnormalities.
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Transcatheter aortic valve implantation (TAVI) has been introduced to treat patients at high risk for conventional surgery; however, cardiogenic shock is considered a contraindication for TAVI. The aim of the present study was to evaluate early and intermediate mortality of patients in cardiogenic shock undergoing TAVI as a rescue procedure. Patients in cardiogenic shock underwent transapical TAVI with Edwards SAPIEN (Edwards Lifesciences, Irvine, CA, USA) prosthetic valves. Preoperative, perioperative and 1-year follow-up data were analysed. Analysis included 358 patients. Preoperative cardiogenic shock was present in 21 (5.9%) patients. EuroSCORE (cardiogenic shock 73.1 ± 18.9% vs. non-cardiogenic shock 36.0 ± 18.7%; P < 0.0001) and Society of Thoracic Surgeons score (cardiogenic shock 50.8 ± 28.1% vs. non-cardiogenic shock 16.7 ± 12.2%; P < 0.0001) were significantly higher in the cardiogenic shock group, and left ventricular ejection fraction (cardiogenic shock 26.0 ± 13.1% vs. no-cardiogenic shock 51.4 ± 13.0%; P < 0.0001) was significantly lower. Thirty-day mortality was significantly higher in the cardiogenic shock group (cardiogenic shock 19% vs. non-cardiogenic shock 5%; P = 0.02) and 1-year survival significantly lower (cardiogenic shock 46% vs. no-cardiogenic shock 83%; P < 0.0001). At Cox regression, EuroSCORE was the sole determinant for follow-up mortality (odds ratio = 1.02; P = 0.04). TAVI in patients who are in cardiogenic shock is feasible. Although the early and late outcomes are encouraging, a structured strategy should be developed and further experience is needed.
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Cardiogenic shock represents a complication in up to 10% of patients with acute myocardial infarction. Cardiogenic shock mortality remains high. In the contemporary treatment inhibitors of NO synthase are studied, apart from classic medications. Mechanical circulatory support is also important in majority of patients with cardiogenic shock: intraaortic balloon contrapulsation, left ventricular assist device systems. Prognosis is improved by percutaneous coronary intervention.
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The clinical history, standard 12-lead electrocardiogram (ECG), and markers of myocardial necrosis constitute the basis for diagnosis and accurate risk assessment in patients with suspected of a non-ST-elevation acute coronary syndrome (NSTEACS). Cardiac troponin T and cardiac troponin I are ideal biochemical markers for the detection of myocardial necrosis in unstable patients who have repeated episodes of ischemia of varying intensity and several days' duration, owing to their high sensitivity and specificity and their long duration of elevation. The troponins are independently predictive of mortality as well as of new or recurrent acute myocardial infarction after an episode of NSTEACS. By integrating the clinical history, ECG findings, and troponin results, it is possible to stratify the patients into low-, intermediate-, and high-risk groups. In addition, troponin results are useful for selecting patients who benefit from treatment with lowmolecular-weight heparin, glycoprotein IIb/IIIa antagonists, and invasive management.
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Cardiogenic shock is a severe cardiovascular disease. If treated properly,the survivors of cardiogenic shock would have better prognosis. Recently,great advances have been obtained in the treatment of cardiogenic shock including drug treatment,intra-aortic balloon counterpulsation,reperfusion,left ventricular assist devices and in turn providing the main managements.
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