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J Cardiovasc Echogr. 2017 Jul-Sep; 27(3): 99–100.
PMCID: PMC5516448

ST-elevation Myocardial Infarction: An Unusual Presentation of Infective Endocarditis

Abstract

Acute coronary syndrome is an uncommon complication in patients with infective endocarditis, either in the acute phase of infection or later in the course. We describe a case of unusual presentation of infective endocarditis as ST-elevation myocardial infarction secondary to coronary embolization from mitral valve endocarditis.

Keywords: Acute coronary syndromes, infective endocarditis, ST-elevation myocardial infarction

INTRODUCTION

Acute coronary syndrome (ACS) is an uncommon complication in patients with infective endocarditis, either in the acute phase of infection or later in the course.[1] We describe a case of infective endocarditis (IE) that presented with ST-elevation myocardial infarction (STEMI).

CASE REPORT

A 69-year-old man with medical history of hypertension and recreational drug use was brought into the hospital after being found on the bathroom floor. He was confused and complained of generalized pain and weakness. Cardiovascular examination revealed normal heart sounds without murmurs gallops or rubs but tachycardia with irregularly irregular rhythm. Electrocardiogram showed atrial fibrillation with rapid ventricular response left axis deviation and ST-elevation with Q waves in anterolateral leads [Figure 1]. The patient was emergently taken for cardiac catheterization. Coronary angiogram showed thrombotic occlusion of distal left anterior descending artery with thrombolysis in myocardial infarction (TIMI) 0 flow without any evidence of atherosclerotic disease [Figure 2 and Video 1]. Percutaneous coronary intervention was unsuccessful due to inability to cross the lesion. The blood cultures sent on admission came back positive for methicillin-resistant Staphylococcus aureus, and he was started on intravenous antibiotics. He underwent transesophageal echocardiogram, which showed large (16 mm × 20 mm), mobile, multilobulated vegetation on anterior mitral valve leaflet without significant regurgitation [Figure 3 and Video 2]. He continued to have positive blood cultures despite being treated with appropriate intravenous antibiotics. His clinical condition deteriorated requiring vasopressor support and mechanical ventilation. Magnetic resonance imaging (MRI) of the brain confirmed multiple small embolic infarcts [Figure 4]. He was deemed to be a poor candidate for surgical intervention and died shortly after withdrawal of life-support as per family's wishes.

Figure 1
Electrocardiogram on presentation showing atrial fibrillation with rapid ventricular response, left axis deviation and ST-elevation with Q waves in anterolateral leads. Q waves were also noted in inferior leads
Figure 2
Coronary angiogram showing left coronary system. Complete occlusion of distal left anterior descending artery with thrombolysis in myocardial infarction (TIMI) 0 flow (arrow). The vessels otherwise had smooth lumens without evidence of atherosclerotic ...
Figure 3
Transesophageal echocardiogram showing a large (16 mm × 20 mm), mobile, multilobulated vegetation on anterior mitral valve leaflet (arrows) without significant regurgitation. There was no left atrial appendage thrombus
Figure 4
T2-weighted magnetic resonance imaging of the brain showing multiple embolic strokes (arrow)

DISCUSSION

ACS, as a result of coronary embolism, occurs in about 1% of the patients with IE. It is more common with mitral valve endocarditis and normally occurs in the acute phase of the disease (first 15 days).[1,2] This case demonstrates an unusual presentation of IE as STEMI secondary to coronary embolization from mitral valve endocarditis. Many of these patients have evidence of systemic embolism at other sites[1,2] as in our patient who had evidence of embolic stroke on MRI of the brain. Higher risk is associated with anticoagulation, fibrinolysis, and percutaneous coronary intervention in these patients.[3] The necessity for the timely restoration of coronary artery perfusion may prevent endocarditis from being diagnosed before cardiac catheterization. However, a high index of suspicion and appropriate work-up is warranted especially in the absence of atherosclerotic disease on coronary angiogram.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Videos available on: www.jcecho.org

References

1. Manzano MC, Vilacosta I, San Román JA, Aragoncillo P, Sarriá C, López D, et al. Acute coronary syndrome in infective endocarditis. Rev Esp Cardiol. 2007;60:24–31. [PubMed]
2. Vilacosta I, Graupner C, San Román JA, Sarriá C, Ronderos R, Fernández C, et al. Risk of embolization after institution of antibiotic therapy for infective endocarditis. J Am Coll Cardiol. 2002;39:1489–95. [PubMed]
3. Herzog CA, Henry TD, Zimmer SD. Bacterial endocarditis presenting as acute myocardial infarction: A cautionary note for the era of reperfusion. Am J Med. 1991;90:392–7. [PubMed]

Articles from Journal of Cardiovascular Echography are provided here courtesy of Wolters Kluwer - Medknow