The Youngest STEMI I Have Seen!

Dr. Ka-Hei HO, Dr. Ho LAM

Tuen Mun Hospital, Hong Kong

A 26-year-old gentleman, with good past health, was admitted for chest pain for 1 hour. ECG showed ST elevation over inferior and posterior leads. He was given TNK. However, he complained of persistent chest pain and there was no resolution of ST elevation, therefore rescue PCI was performed.

Emergency coronary angiogram showed distal RCA total occlusion with TIMI 0 flow (Movie 1). Predilated with semi-compliant balloon 1.5/15 at low pressure. However, patient developed hypotension requiring dopamine and sustained VT necessitating cardioversion afterwards. Repeated angiogram showed improving flow but distal PL was still totally occluded (Movie 2). We decided for mechanical thrombus aspiration with Penumbra Indigo CAT-RX system. Red clots were aspirated (Figure 1, Figure 2, Figure 3). After thrombus aspiration, TIMI III flow restored (Movie 3). Patient’s haemodynamic status was stabilized and chest pain also improved. We decide to stop the procedure in view of improved flow and stabilized haemodynamics.

Coronary angiogram was repeated two days later. It showed TIMI III flow at RCA (Movie 4). IVUS was performed and it showed moderate plaque burden at PL and organized thrombus at the pRCA aneurysm, and there was no plaque rupture or dissection (Figure 4, Movie 5). We decided not for stenting of the lesion as we concluded that cause of STEMI in this young gentleman is cardioembolism due to clots formation at pRCA aneurysm and only moderate plaque burden noted.

We started him on aspirin and NOAC as anti-thrombotic treatment. He had clear evidence of atherosclerosis without ruptured plaque on IVUS. NOAC was started as the mechanism for STEMI is cardioembolism due to coronary artery aneurysm.

He remained well after PCI. He remained chest pain free during follow-up.

Conclusion

  • STEMI does occur in young, keep in mind about the different etiologies in young population
  • No single way of treating thrombus, ‘’think from the patient to the lesion’’
  • Stenting is not a ‘’must’’
  • Personalized treatment regime including antithrombotic regime and risk factors control