A (Not So) Rare Case of Acs in a Young Woman

Abstract A 39 yo Caucasian woman, former smoker, with a previous history of gestational hypertension requiring therapy for several months, presented to the ED with persistent oppressive chest pain. No prior ischemic, constitutional or inflammatory symptoms emerged. Physical examination revealed a left carotid bruit and a continuous murmur at the base, Killip I. The ECG showed negative T waves in the inferior leads, the echo “point of care” normal systolic function, akinesia of the inferior wall, moderate aortic insufficiency, normal dimensions of the ascending aorta. HS T troponin rose to 188 ng/L and NT–proBNP 1621 pg/mL, CPR was normal. Coronary angiography revealed a tight subocclusive stenosis of the proximal right coronary artery trated by angioplasty with drug–eluting stent placement. In the ICU diminished pedal pulses were noticed, along with a significant discrepancy in blood pressure values between the four limbs (right upper 150/60 mmHg, left 140/60 mmHg, lower right 70/40 mmHg, left 60/40 mmHg). The echocardiogram showed normalized LV kinesis, moderate aortic insufficiency, normal dimensions of the ascending aorta and arch, flow acceleration at the isthmus (Vmax 4.6 m/s, Gmax 86 mmHg). CT angiography revealed thickening of the walls of the epiaortic vessels (with a non critical stenosis of the left carotid), of the thoracic and the abdominal aorta with complete occlusion of the subrenal segment and the inferior mesenteric artery (reconstituted by the Riolano artery and distal rectal arteries); the distal iliac arteries at the carrefour were separately reconstituted. 18F–FDG PET/CT confirmed diffuse hypercaptation along the ascending aorta, isthmus and proximal descending portion indicative of active vasculitis. Elevation of ESR 110 mm/h and CRP 21 mg/L was observed. The diagnosis of Takayasu‘s arteritis (TA) was estabilished and treatment with prednisone and methotrexate was started, resulting in the normalization of acute phase markers and clinical stability at 3 months. TA is a vasculitis that primarily involves the aorta and its main branches. The diagnosis can be challenging due to the heterogeneous clinical course and lack of specific laboratory markers. Diagnostic delay and persisting inflammation can lead to catastrophic consequences. Despite its rarity, TA can account for a notable proportion of young women with documented myocardial ischemia; hence, cardiologists must be sensitive to this pathology particularly in high–risk populations.