Posters
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Internal Medicine
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Internal Medicine
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Internal Medicine
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Internal Medicine
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Patient Care
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Case Report
Abstract
Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is an emergent cardiac condition that comprises less than 15% of acute MI patients. Both conditions can present similarly with anterior chest pain, dyspnea, and elevated cardiac biomarkers. Despite these similarities, their treatment and prognosis will differ drastically.
Case Presentation: A 33-year-old Hispanic male with no previous medical history arrived at the emergency department with a chief complaint of chest pain. He was awoken by a 10/10 pressure-like radiating pain located in the anterior chest, accompanied with diaphoresis, dyspnea and palpitations. He endorsed consistent pain since onset and denied any alleviating or aggravating factors. He denied any history of C.A.D. and denied any similar symptoms previously. Of note, he also stated that he had experienced flu-like symptoms four days prior, with a max temperature of 39℃. These symptoms were resolved with ibuprofen and amoxicillin.
Upon arrival at the ED, his vital signs were within normal limits but presented with significantly increasing serial troponins and elevated CRP/CK levels. An initial EKG showed significant ST elevations in the inferior leads with reciprocal ST depressions, yielding a concern for a potential acute inferior STEMI. Given this, a repeat EKG was ordered, which confirmed persistent ST elevations. ACS protocol was activated, and the patient was prepared for an interventional left heart catheterization. He was also started on IV heparin bolus and infusion, aspirin 324 mg, and ticagrelor 180 mg for anticoagulation prior to the procedure. Emergency angiography revealed widely-patent coronary vessels and preserved systolic function with no evidence of stress-induced cardiomyopathy, thus alleviating concern for obstructive coronary disease.
Coupled with these findings, viral laboratory studies ordered on arrival to the ED showed a presence of Coxsackie A24 and B3-B5 antibodies, prompting a diagnosis of Coxsackie virus-induced myocarditis, a subtype of MINOCA. Our patient was transitioned to a year-long regimen of dual antiplatelet therapy consisting of aspirin and clopidogrel and initiated on Metoprolol. Additionally, he received pulsed-dose Solu-Medrol 125 mg. This combination of treatments resulted in a complete resolution of his symptoms. He was discharged after a 48-hour hospital stay and advised to refrain from strenuous physical activity for six months. One week post hospitalization, the patient reported complete resolution of symptoms without any sequelae.
Conclusions: Considering the similarities of ACS vs MINOCA, this case highlighted the importance of taking a thorough history, as the recent viral prodrome and lack of comorbidities led to a working diagnosis of MINOCA from the start. Although the diagnostic interventions are necessary in order to diagnose by exclusion, the history taken was able to yield a prompt treatment and complete resolution of symptoms.
Recommended Citation
Abrego, Edwardo II; Trujillo-Acosta, Mario; Ackerman, Laura; and Garcia, Laura, "Beyond the Plaque: Viral Myocarditis Masquerading as ACS" (2025). Research Symposium. 56.
https://scholarworks.utrgv.edu/somrs/2025/posters/56
Included in
Beyond the Plaque: Viral Myocarditis Masquerading as ACS
Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is an emergent cardiac condition that comprises less than 15% of acute MI patients. Both conditions can present similarly with anterior chest pain, dyspnea, and elevated cardiac biomarkers. Despite these similarities, their treatment and prognosis will differ drastically.
Case Presentation: A 33-year-old Hispanic male with no previous medical history arrived at the emergency department with a chief complaint of chest pain. He was awoken by a 10/10 pressure-like radiating pain located in the anterior chest, accompanied with diaphoresis, dyspnea and palpitations. He endorsed consistent pain since onset and denied any alleviating or aggravating factors. He denied any history of C.A.D. and denied any similar symptoms previously. Of note, he also stated that he had experienced flu-like symptoms four days prior, with a max temperature of 39℃. These symptoms were resolved with ibuprofen and amoxicillin.
Upon arrival at the ED, his vital signs were within normal limits but presented with significantly increasing serial troponins and elevated CRP/CK levels. An initial EKG showed significant ST elevations in the inferior leads with reciprocal ST depressions, yielding a concern for a potential acute inferior STEMI. Given this, a repeat EKG was ordered, which confirmed persistent ST elevations. ACS protocol was activated, and the patient was prepared for an interventional left heart catheterization. He was also started on IV heparin bolus and infusion, aspirin 324 mg, and ticagrelor 180 mg for anticoagulation prior to the procedure. Emergency angiography revealed widely-patent coronary vessels and preserved systolic function with no evidence of stress-induced cardiomyopathy, thus alleviating concern for obstructive coronary disease.
Coupled with these findings, viral laboratory studies ordered on arrival to the ED showed a presence of Coxsackie A24 and B3-B5 antibodies, prompting a diagnosis of Coxsackie virus-induced myocarditis, a subtype of MINOCA. Our patient was transitioned to a year-long regimen of dual antiplatelet therapy consisting of aspirin and clopidogrel and initiated on Metoprolol. Additionally, he received pulsed-dose Solu-Medrol 125 mg. This combination of treatments resulted in a complete resolution of his symptoms. He was discharged after a 48-hour hospital stay and advised to refrain from strenuous physical activity for six months. One week post hospitalization, the patient reported complete resolution of symptoms without any sequelae.
Conclusions: Considering the similarities of ACS vs MINOCA, this case highlighted the importance of taking a thorough history, as the recent viral prodrome and lack of comorbidities led to a working diagnosis of MINOCA from the start. Although the diagnostic interventions are necessary in order to diagnose by exclusion, the history taken was able to yield a prompt treatment and complete resolution of symptoms.
