CORRESPONDENCE: LETTER TO THE EDITOR
Myocardial Infarction in the Absence of Obstructive Epicardial Coronary Disease
Kevin A. Bybee, MD and
Charanjit S. Rihal, MD*
* Cardiac Catheterization Laboratory, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905 (Email: Rihal{at}mayo.edu).
We read with interest the study by Dokainish et al. (1) reporting characteristics and outcomes of patients with acute coronary syndromes in the absence of obstructive epicardial coronary disease in a post hoc analysis of the TACTICS-TIMI-18 trial. Six percent of patients presenting with an apparent acute coronary syndrome (ACS) and troponin elevation were found to have no significant epicardial disease at angiography. These patients were more likely to be female, and rates of death and reinfarction were lower in this group at six months when compared with those who had angiographically significant coronary disease, regardless of troponin elevation.
The investigators discuss potential mechanisms of myocardial infarction in patients without significant epicardial coronary disease, but they do not consider transient left ventricular apical ballooning syndrome (TLVABS) as a potential explanation in some of these patients (2–6). In a recent systematic review of TLVABS, we and others have pointed out that these patients are typically postmenopausal females who present with acute-onset ischemic cardiac symptoms, electrocardiographic changes, mildly elevated cardiac biomarkers, and characteristic yet transient apical and midventricular wall motion abnormalities in the absence of obstructive epicardial coronary disease (7). The risk of mortality associated with the syndrome appears to be low and recurrence uncommon. It may be that some of the reported patients presenting with an apparent ACS with troponin elevation in the absence of obstructive epicardial coronary disease had TLVABS, which in turn may explain the observed lower rates of mortality and reinfarction in this patient cohort.
Finally, TLVABS is underrecognized and should be considered in the differential diagnosis of patients presenting with an apparent ACS in the absence of obstructive coronary artery disease. The mechanisms responsible for TLVABS are unknown and deserve further investigation.
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1. Dokainish H, Pillai M, Murphy SA, et al. Prognostic implications of elevated troponin in patients with suspected acute coronary syndrome but no critical epicardial coronary disease: a TACTICS-TIMI-18 Substudy J Am Coll Cardiol 2005;45:19-24.[Abstract/Free Full Text]
2. Tsuchihashi K, Ueshima K, Uchida T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction J Am Coll Cardiol 2001;38:11-18.[Abstract/Free Full Text]
3. Bybee KA, Prasad A, Barsness GW, et al. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome Am J Cardiol 2004;94:343-346.[CrossRef][Web of Science][Medline]
4. Kurisu S, Sato H, Kawagoe T, et al. Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction Am Heart J 2002;143:448-455.[CrossRef][Web of Science][Medline]
5. Abe Y, Kondo M, Matsuoka R, Araki M, Dohyama K, Tanio H. Assessment of clinical features in transient left ventricular apical ballooning J Am Coll Cardiol 2003;41:737-742.[Abstract/Free Full Text]
6. Desmet W, Adriaenssens B, Dens J. Apical ballooning of the left ventricle: first series in white patients Heart 2003;89:1027-1031.[Abstract/Free Full Text]
7. Bybee KA, Kara T, Prasad A, et al. Transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction Ann Intern Med 2004;141:858-865.[Abstract/Free Full Text]
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