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Abstract Introduction Myocardial Infarction with Non–Obstructive Coronary Artery disease (MINOCA) is an increasingly recognized clinical entity requiring a comprehensive and precise work–up to detect the correct diagnosis and to appropriately institute treatment strategies. We report a case explanatory of a rare cause of MINOCA, highlighting the importance of a comprehensive diagnostic algorithm. Case A 55 years old man with an intermediate cardiovascular risk profile and no prior medical history presented to the emergency department. He experienced typical chest pain at rest 6 days prior to admission, but refused to attend the hospital and, instead, performed outpatient labs on day 5 demonstrating elevated high sensitivity troponin I (Hs–TnI, 3192 ng/L). At admission, the patient was asymptomatic and well compensated. The ECG was normal, echocardiography revealed a mid–basal inferior hypokinesia, and lab. exams showed a hs–TnI of 159 ng/L. The coronary angiogram was normal: no atherosclerosis was present and, upon independent revision of the images from experienced operators, no coronary dissection, myocardial bridges or emboli were observed. Ventriculography ruled–out ongoing Takotsubo Cardiomyopathy, nor the history was suggestive of any trigger. No clinical, ECG and echocardiographic features of myocarditis or cardiomyopathy were present and a classic troponin curve was observed. No clinical features of endocarditis were present. No ventricular or atrial arrhythmias were detected on continuous monitoring. A working diagnosis of MINOCA was established. Cardiac magnetic resonance revealed a focal area of transmural late gadolium enhancement and T2–based enhancement of the inferior mid–basal wall consistent with acute myocardial damage. In the suspect of an embolic source, transesophageal echocardiogram documented the presence of a patent foramen ovale (PFO) with characteristics at high embolic risk: large aneurysmatic fossa ovale type 4 LR (Olivares Reyes) with left to right shunting at baseline which increased during Valsalva maneuver, prominent Chiari network and Eustachian valve. Given the high probability of association between PFO and systemic embolism phenomena, percutaneous closure of the PFO was proposed. Conclusion With this case we want to highlight the importance of the correct and precise diagnostic work up in this emerging pathology in the field of cardiology for a better definition of the therapeutic strategy.
Peano et al. (Mon,) studied this question.