Myocardial Infarction in Patients with Systemic Lupus Erythematosus with Normal Findings from Coronary Arteriography and Without Coronary Vasculitis

Abstract

The authors present the cases of two young patients, a man and a woman, who presented with myocardial infarction, in the absence of ischemic heart disease or stenosis of the coronary arteries. The woman was known to have systemic lupus erythematosus (SLE) for the past 3 years (the immunoglobulin M [IgM] anticardiolipins antibodies were positive), without a history of coronary risk factors. Suddenly she presented with acute chest pain on rest that lasted 4 hours and culminated in anterior wall myocardial infarction. She was admitted to the coronary care unit, where no thrombolysis was given. She did not have echocardiographic evidence of Libman-Sacks endocarditis, but myocardial infarction was evident at the electrocardiogram (ECG). The young man had SLE (the IgM anticardiolipins were absent, but he was positive for lupus anticoagulant antibodies), he was hyperlipidemic, was a moderate smoker and moderately obese, and had no history of ischemic heart disease. He suddenly presented with an acute myocardial infarction documented by ECG, enzymes, and gammagraphy. In both patients, coronary angiography findings were normal and myocardial biopsy did not show evidence of arteritis. The relevance of these cases is the rare association of ischemic heart disease in SLE, with normal coronary arteries and without evidence of arteritis or verrucous endocarditis.

A 26‐year‐old white man with a systemic lupus erythematosus flare and acute multiorgan ischemia: Vasculitis or thrombosis?

“…It was presumed that clear coronary vessels could be due to resolution of thrombosis/spontaneous thrombolysis, coronary vasospasm, coronary emboli from Libman-Sacks endocarditis/ mural ventricular thrombus, or microthrombi. In 2 of these cases, endomyocardial biopsy samples failed to show vasculitis, and in another, autopsy showed arteriolar thrombosis (21,22). All had presence of aPL.…”

“…An extensive evaluation revealed elevated inflammatory markers, including erythrocyte sedimentation rate (ESR; 102 mm/hour), C-reactive protein level (56 mg/liter), positive antinuclear antibodies (ANAs; Ͼ1:640), strongly positive anti-doublestranded DNA (anti-dsDNA) titers, low levels of C4 (9 mg/dl, normal range 16 -38), prolonged prothrombin time (16.2 seconds, normal range 10 -13), prolonged activated partial thromboplastin time (60 seconds, normal range [27][28][29][30][31][32][33][34][35][36][37][38], and positive lupus anticoagulant (LAC) by dilute Russell's viper venom time. His urine analysis showed proteinuria (0.440 gm protein/gm creatinine), hematuria (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) …”

Myocardial perfusion scintigraphy and coronary disease risk factors in systemic lupus erythematosus

“…Homocysteine levels 18 19 and antiphospholipid antibodies 20 21 are some of these factors. Other potential mechanisms for coronary ischaemia, such as vasculitis, 22 23 immune complex deposition, 24 microvascular disease, 25 intracoronary thrombus, 26 and coronary aneurysms, [27][28][29] may also contribute to acute coronary events. Longer duration of SLE, older age at SLE diagnosis, and steroid treatment are also SLE disease related factors that seem to contribute to CAD.…”

Chronic Anabolic Androgenic Steroid Usage Associated with Acute Coronary Syndrome in Bodybuilder

“…Other reported causes of MI include coronary vasculitis, either isolated or secondary to systemic connective tissue disorders like systemic lupus erythematosus and dermatomyositis. 8 Since the CK: Creatine Kinase; CK-MB: Creatine Kinase-MB. Fig.…”