Vasospasm-induced acute myocardial infarction—Thrombus formation without thrombogenic lesion at the culprit

Abstract

a b s t r a c tAlthough plaque rupture is the major cause of acute myocardial infarction, vasospasm is also known as a potential cause of acute myocardial infarction. However, it is very rare and is sometimes difficult to diagnose correctly. A 30-year-old male patient with suspected unstable angina pectoris who received catheterization in 1999 had normal coronary artery but positive result in the provocation test of vasospasm. Although his angina had been suppressed by medications, he suffered ST-elevation acute myocardial infarction after the discontinuation of medication. The initial angiogram showed total occlusion of the proximal left anterior descending coronary artery. Thrombolysis and nitroglycerin achieved recanalization of the culprit lesion with only mild residual stenosis. Angioscopy revealed normal white luminal wall without any thrombogenic lesion. Therefore, the cause of coronary occlusion was diagnosed as vasospasm. However, since the repeated vasospastic occlusion of the culprit lesion regardless of repeated intra-coronary injection of nitroglycerin was observed, a stent was implanted and vasospasm was successfully prevented. It is not easy to judge from the angiogram that the cause of coronary occlusion in the patients with acute myocardial infarction is vasospasm. It is important to think routinely about the possibility of vasospasm as a cause of acute myocardial infarction. <Learning objective: In a patient with acute myocardial infarction caused by vasospasm, angioscopy revealed normal white luminal vessel wall without any thrombogenic lesion at the culprit, although the initial angiogram suggested the presence of thrombus. It is not easy to judge from the angiogram that the cause of coronary occlusion in the patients with acute myocardial infarction is vasospasm.>

Transient increase in blood thrombogenicity may be a critical mechanism for the occurrence of acute myocardial infarction

“…Vasospasm is known to cause acute MI in the patients with nonobstructive coronary arteries without thrombogenic culprit lesion [35]. However, no investigation has ever demonstrated the contribution of vasospasm to the onset of acute MI at the disrupted thrombogenic plaque, although it has been speculated to play an important role.…”

Acute inferior myocardial infarction in a young man with testicular seminoma: A case report

“…Moreover, an increasing body of evidence points to the fact that cisplatin also induces endothelial dysfunction, affecting both the relaxation and contractile function through severe damage to blood vessel walls[ 10 ]. The mechanisms underlying the latter are mainly the reduction of endothelial nitric oxide synthetase and an increase in plasminogen activator inhibitor 1[ 11 ], but also include other mechanisms such as hydrogen sulphide availability[ 12 ]. Thrombus formation is the result of one or more of the following factors that build Virchow’s triad: endothelial dysfunction, hypercoagulation and blood stagnation.…”

ST-Elevation Myocardial Infarction in a 23-Year-Old Female: The Mystery of Thrombus Formation

“…However, severe coronary vasospasm has been reported [3][4]. There have been few reports of severe coronary vasospasm-induced thrombus formation secondary to possible endothelial damage [5][6][7][8][9][10]. Endothelium of the coronary arteries inhibits platelet aggregation by formation and release of prostacyclin, and it reacts to platelet products by causing relaxation of the underlying smooth muscle.…”

“…Cases of AMI from severe coronary vasospasm have been reported with phentermine, a weight loss medication and an amphetamine derivative, but coronary artery thrombosis has not [3][4]. However, the literature review does show the possibility of coronary artery thrombosis secondary to endothelial damage from prolonged severe coronary vasospasm in patients without evidence of atherosclerotic plaque rupture [5][6][7][8][9][10][11]. More recently, coronavirus disease 2019 (COVID-19) has been shown to be associated with various thromboembolic phenomena, however, the majority of cases involving acute coronary artery occlusion have been observed in hospitalized patients with concurrent respiratory failure [12][13][14][15][16][17].…”