Cardiac MRI as the clue in acute chest pain setting

Description of Clinical Presentation: A case of 65 year old male patient who presented with chest pain, sweating and vomiting for a few hours. The patient was with history of coronary artery disease with PTCA balloon dilatation of LCX five years ago and a 50 % proximal LAD stenosis , FFR 0,9. Ambulatory medication consisted of Aspirin 100 mg, Trombex 75 mg, Concor 5mg, Rosuvastatin 20mg, Valsartan 2x 160 mg and Repatha once every 14 days. At admission laboratory tests showed elevated troponin - 13,5ng/ml. CPK - 963 U/L, CC- MB- 130 U/L, total cholesterol 2,42 mmol/L. ECG showed sinus rhythm , RBB with signs of inferior infarction and ST depression in V1-V3. Ejection fraction was 45% with lateral wall hypokinesia. Patient was sent to cath lab and invasive corongraphy showed 50% proximal LAD stenosis and spontaneous dissection of OM in mid to distal segment was considered due to the tapering of the OM and its branches.The patient was referred to CMR

Diagnostic Techniques and Their Most Important Findings: CMR was perfumed 11 days after onset of chest pain. CMR showed ejection fraction of 49% / slightly improved compared to echo at admission / with regional inferolateral wall akinesia and lateral wall hypokinesia. In the inferior wall a region of thinned myocardium around 4 mm with nearly transmural late gadolinium enhancement with ischemic pattern corresponding to the prior infaction. However there were also two separate regions of edema one located in the basal anterolateral wall and second in in mid lateral wall . The same regions demonstrated LGE

Learning Points from this Case: To recognize that as per most recent guidelines, CMR should be performed and has added value in patients presenting with AMI and equivocal and unexplained findings from the coronarography.

To recognize that CMR can precisely assess the presence and extension of AMI and to differentiate acute from chronic infarction and also to provide prognostic informations in patients with AMI.

T2 image showing regional oedema in mid lateral wall
LGE showing focal region of enhancement in the mid lateral wall corresponding to the region of odema and a nearly transmural ischemic late enhancement pattern
T2 image showing a second region of oedema in basal anterolateral wall