Quick Fire Cases
Shuja A. Malik, MD
Advance Cardiac Imaging Fellow
University of Kentucky
Shuja A. Malik, MD
Advance Cardiac Imaging Fellow
University of Kentucky
James Stock, DO
Fellow
University of Kentucky
Talal S. Alnabelsi, MD
Assistant Professor
University of Kentucky
Preeti Ramachandran, MD
Assistant Professor of Pediatric Cardiology
University of Kentucky
17-year-old male high school football player who presented to an outlying hospital after developing substernal chest pain radiating to the left jaw an hour after returning from football practice. Troponin I was elevated (121, range 4-76ng/L). ECG showed ST segment elevation in the inferior limb leads with reciprocal depression. An echocardiogram revealed LVEF in the 50-55% range, along with mild mid and inferoseptal wall hypokinesis. He was taken to the cath lab at this time due to persistent ST segment changes. Coronary angiography revealed a partially occlusive thrombus in the proximal segment of the right coronary artery with evidence of abrupt cut-off of the distal posterolateral branches (see figure). IV Tirofiban and ticagrelor were started, and the patient was transferred to our hospital.
Diagnostic Techniques and Their Most Important Findings:
Repeat high sensitive troponin levels were 848ng/L (normal < 15ng/L). Repeat echo with agitated saline study showed no evidence of intracardiac shunting. A coronary CT angiogram was performed, which revealed a plaque in the proximal right coronary artery (Figure). A cardiac MRI was performed to rule out acute myocarditis. CMR demonstrated multiple small foci of late gadolinium enhancement in the subendocardial region in the distribution of the right coronary artery consistent with infarct (Figure). CMR findings favored embolism likely from proximal ruptured atherosclerotic plaque rather than myocarditis. Labs were notable for hypercholesterolemia with an LDL-C of 175 mg/dL which prompted further work up for familial/genetic causes of hypercholesterolemia. The patient was discharged home on dual antiplatelet and high intensity statin therapy with close cardiology follow up.
Learning Points from this Case:
This case highlights the utility of advanced cardiovascular imaging in changing clinical management in rare cases of acute coronary syndrome in pediatric patients.
