The diagnostic dilemma of myocardial infarction with unobstructed coronary arteries

Abstract

Cardiovascularmagnetic resonance imaging(CMR) is increasingly used in modern cardiology to complement the diagnostic work-up of patients with cardiovascular diseases,and to contribute torisk stratification and patientmanagement.We describe a case of a patient in whomCMR waspivotal inreachingthefinaldiagnosis which carried important implication for patient management and prognosis.
A 72-year-old woman presented to the emergency department with intense crushingcentral chestpain,notradiatingtoarms/jaw.After clinical assessment, bloodtests, echocardiographyand angiography,which showed un­obstructed coronary arteries, the patientwas discharged with adiagnosis of acute myocarditis. She wastreated accordingly, and referred for CMR for confirmation of the diagnosis. TheCMR revealedmyocardial oedema and myocardialscarring. In view of the unobstructed coronary arteries on angio­graphy, this is consistent with a recent myocardial infarctionwithspontaneous recanalisation. Therefore,the final discharge diagnosis was changed from myocarditis to recent myocardial infarction andthe patient’s therapy was modified accordingly (she was started on secondary prevention therapy).
This case illustrates the increasing clinical role of CMR inpatientswith acute coronary syndrome and unobstructed coronary arteries, andits usefulness in reachingthe correctdiagnosis, whichhas important implicationsfor clinical management.