Multimodality imaging in a young patient with antiphospholipid syndrome-related acute myocardial infarction

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A 22-year-old male presented with pleuritic chest pain following acute gastroenteritis. Cannabis was smoked 6 h prior to admission. Electrocardiogram demonstrated diffuse ST-segment elevation (Panel A). Echocardiogram revealed apical akinesis (Panel B; Supplementary data online, Video S1). Troponin and inflammatory markers were elevated. Differential diagnosis included perimyocarditis and acute myocardial infarction (AMI). Coronary angiography revealed filling defects in the proximal left anterior descending (LAD) coronary artery and distal occlusion (Panel C; Supplementary data online, Videos S2 and S3). Intravascular ultrasound confirmed high LAD thrombus burden (Panel D). Coronary intervention was deferred due to preserved proximal coronary flow, high thrombus burden, and suspected hypercoagulable state. Aspirin, clopidogrel, tirofiban, heparin, statin, and colchicine were initiated.

Computed tomography revealed non-obstructive, non-calcified LAD plaque with positive remodelling and small thrombus (Panel E). Magnetic resonance imaging showed apical transmural late gadolinium enhancement, supporting AMI (Panel F; Supplementary data online, Video S4). A week later, repeat coronary angiography revealed improved LAD flow with a persistent distal filling defect (Panel G; Supplementary data online, Video S5). Optical coherence tomography depicted proximal LAD plaque erosion with red (Panel H) and white thrombus (Panel I). Lipid profile including lipoprotein(a) was normal. Lupus anticoagulant titre was high, suggestive of antiphospholipid antibody syndrome (APS). The patient was discharged with warfarin and antiplatelet therapy.

Acute myocardial infarction in young adults is uncommon. An interplay between APS, a causative factor for vascular thrombosis, with proinflammatory and prothrombotic precipitators (smoking and infectious disease), may have occurred. This case highlights the diagnostic challenges posed by AMI at a young age and the importance of multimodality imaging in achieving an accurate diagnosis and effective treatment plan.

Supplementary data are available at European Heart Journal - Cardiovascular Imaging online.

Funding: None declared.

Data availability: The data underlying this article will be shared on reasonable request to the corresponding author.

Author notes