Acute myocardial infarction with normal coronary artery (MINCA) in a patient with multiple sclerosis

Abstract

Objective: Interestingly, some patients with STEMI have normal coronary artery anatomy at cooronary angiography. This situation is called as MINCA (acute myocardial infarction with normal coronary artery). The incidence of MINCA varies between 1.0 and 8.5%. Although some reasons have been propounded, the exact underlying mechanism remains unclear. Methods: A 36-year-old woman without a history of any cardiovascular disease was admitted to our hospital because of typical chest pain for 2 hours. She had a history of mutliple sclerosis (MS) for 5 years. An admission 12-lead ECG showed ST elevation in leads II, III, aVF and reciprocal changes in leads V1, V2, suggesting an acute inferior myocardial infarction. CAG was performed. Interestingly, CAG did not reveal any stenosis, luminal irregularities, thrombus or coronary spasm. The patient took in coronary intensive care unit and treated with infusion of unfractioned heparin and glyceryl trinitrate at recommended dose for the possibility of thrombus embolization into the microvascular integrity. Cardiac enzymes were elevated 2.5 hours. Echocardiogram showed inferior hypokinesis. Her chest pain recurred and same ECG finding suggesting an acute inferior myocardial infarction were found at the 2nd day of hospitalization. CAG repeated and revealed normal coronary arteries once more. She also complained of dizziness, nausea and vomiting. Magnetic resonance imaging (MRI) was performed and revealed multiple foci of increased T2 signal intensity, but there was not any new foci suggesting MS exacerbation. The patient was treated with infusion of methylprednisolone at recommended dose for five days. Her chest pain did not occurred again during hospitalization and the patient was discharged in a very good condition at the 7th day of hospitalization. We thought about the possibility of coronary vasospasm or intra-luminal thrombosis resolved spontaneously. Either clear atherosclerosis or thrombus formation was not present at CAG. Conclusions: In literature, there is limited case reports pointing the relationship between angina pectoris or myocardial ischemia and MS. Patients with MS have been shown to be at risk for various forms of cardiovascular dysfunction. Sympathetic preganglionic nerve fibers of the heart originate form neurons in the upper four-to-five thoracic segments of the thoracic spinal cord have an important role in regulating cardiac function and myocardial blood flow. It has been shown that the thoracic spinal cord lesion led to coronary vasoconstriction due to intense activation of cardiac sympathetic nerves. A lesion in the stated segments of the spinal cord may be the cause of coronary vasospasm in our patient with MS.