Fingerprinting MINOCA: Unraveling Clues With Quantitative CMR.

In the following case series, we describe the clinical presentation of 2 patients with myocardial infarction with nonobstructive coronary arteries with different underlying pathophysiologic mechanisms. In both scenarios, cardiac magnetic resonance (CMR) imaging provided comprehensive tissue characterization with both conventional parametric mapping techniques and CMR fingerprinting. These cases demonstrate the diagnostic utility for CMR to elucidate the underlying etiology and appropriate therapeutic strategy. (Level of Difficulty: Advanced.).

Chest Pain and the Dynamic Evolution of Spontaneous Coronary Artery Hematoma.

Spontaneous coronary intramural hematoma (SCIH) is a rare but underdiagnosed condition, with dynamic evolution. We present a patient with acute chest pain and normal coronary angiogram undergoing work-up for myocardial infarction with nonobstructive coronary arteries. Cardiac magnetic resonance revealed an ischemic pattern, and subsequent angiography revealed coronary occlusion by SCIH. (Level of Difficulty: Intermediate.).

Recurrent Myocardial Infarction in a Patient With MINOCA and a Negative Ergometrine Provocation Test.

This case highlights the diagnostic challenge associated with coronary vasospasm, especially when accompanied by no provoked spasms on the ergometrine test in the acute setting of myocardial infarction with nonobstructive coronary arteries. Inexplicable myocardial infarction with nonobstructive coronary arteries after extensive evaluation should alert the clinician to the possibility of coronary vasospasm and the necessity of acetylcholine provocative testing in spite of a negative ergometrine provocation test. (Level of Difficulty: Intermediate.).

Nuances in the Evaluation of Chest Pain in Women.

Although chest pain is the most common presenting symptom for both men and women who ultimately receive diagnoses of acute coronary syndrome, there in are important differences in coronary artery disease pathophysiology that can affect patient care. Using a case-based approach, we provide insight into these and other important considerations that every clinician should think of when treating women with chest pain. (Level of Difficulty: Intermediate.).

Premature Myocardial Infarction: A Community Study.

OBJECTIVE: To evaluate the trends in incident premature myocardial infarction (MI) and prevalence of cardiac risk factors in a population-based cohort. METHODS: We studied a population-based cohort of incident premature MIs among residents (MI in men aged 18-55 years and women aged 18-65 years) in Olmsted County, Minnesota, during a 26-year period from January 1, 1987 through December 31, 2012. Recurrent MI and death after incident premature MI were enumerated through September 30, 2018. RESULTS: Of 3276 MI cases, 850 were premature events (37.9% [322/850] women). Age-adjusted premature MI incidence rates (2012 vs 1987) declined by 39% in men (rate ratio, 0.61; 95% CI, 0.46 to 0.81]) and 61% in women (rate ratio, 0.39; 95% CI, 0.27 to 0.57). Among men with premature MI, the prevalence of hypertension, diabetes, and hyperlipidemia increased over time, whereas in women, only the prevalence of hyperlipidemia increased. During a mean follow-up of 13.3 years, there was no temporal decline in recurrent MI in men and women. Women showed 66% decreased risk for mortality (hazard ratio, 0.34; 95% CI, 0.17 to 0.68) over time, whereas men showed no change. CONCLUSION: The incidence of premature MI declined over a 26-year period for both men and women. The risk factor profile of persons presenting with MI worsened over time, especially in men. Death following incident MI declined only in women. These results underscore the importance of primary prevention in young adults and of sex-specific approaches.

A Challenging Case of Extensive Spontaneous Coronary Artery Dissection.

The detection of spontaneous coronary artery dissection (SCAD) causing myocardial infarction is integral in pursuing the appropriate management. Our case posed a diagnostic challenge, with Takotsubo cardiomyopathy and coronary embolism among the potential differential diagnoses upon the initial presentation. Extensive propagation of spontaneous coronary artery dissection subsequently resulted in a significant challenge to management requiring surgical revascularization. (Level of Difficulty: Intermediate.).

A Challenging and Unexpected Case of MINOCA Using Multimodality Imaging.

We describe a challenging case of a patient with MINOCA due to isolated right ventricular myocardial infarction with microvascular obstruction identified on cardiac magnetic resonance imaging. This case highlights that even a comprehensive, guideline-based assessment of these patients can initially fail to detect the underlying pathology. (Level of Difficulty: Beginner.).

Circulating Heterophile Antibodies Causing Cardiac Troponin Elevation: An Unusual Differential Diagnosis of Myocardial Disease.

We present the case of a female patient who developed persistently elevated levels of cardiac troponin (cTn) after a previous episode of clinically presumed myocarditis. Extensive investigation concluded that the presence of heterophile antibodies was causing false positive cTn elevation. (Level of Difficulty: Intermediate.).