A Stepwise Diagnostic Approach to Transmural Myocardial Infarction With Non-obstructive Coronary Arteries With Microvascular Obstruction Highlighting the Role of Cardiac MRI in Suspected Thrombolysis

TL;DR

This paper presents a case where cardiac MRI helped diagnose a heart attack despite normal coronary arteries, suggesting spontaneous blood clot breakdown.

Contribution

Highlights the role of cardiac MRI in diagnosing MINOCA and suggests spontaneous thrombolysis as a possible mechanism.

Findings

Cardiac MRI identified transmural myocardial infarction with microvascular obstruction in a patient with normal coronary angiography.

The case suggests spontaneous thrombolysis as a potential explanation for MINOCA with microvascular obstruction.

The absence of obstructive coronary lesions and presence of MRI findings led to a revised diagnosis of MINOCA.

Abstract

Myocardial infarction with non-obstructive coronary arteries (MINOCA) presents a diagnostic challenge due to its heterogeneous etiologies and the absence of obstructive coronary lesions. We report the case of a 74-year-old male with hypertension, prior deep vein thrombosis, and a history suggestive of thrombophilia under evaluation, on chronic warfarin therapy, who presented with chest pain, ST elevation, and elevated troponins. Coronary angiography revealed no obstructive coronary artery disease. Cardiac magnetic resonance imaging (MRI) demonstrated an acute transmural myocardial infarction with microvascular obstruction in the left anterior descending artery region. Alternative cardiac and extracardiac causes were excluded, and the diagnosis was revised to MINOCA. This case underscores the diagnostic power of cardiac MRI and suggests spontaneous thrombolysis as a plausible mechanism, based on the transmural infarction pattern, presence of microvascular obstruction, and absence of angiographic obstruction.

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