BACKGROUND: Acute ST-elevation myocardial infarction in patients with normal coronary arteries has previously been described, but coronary angiography in these patients was performed after the acute phase of the infarction. It is possible that these patients did not have normal angiograms during the acute phase (transient coronary thrombosis or spasm were usually suspected to be the cause). Information on the prevalence of truly normal coronary angiograms during the acute phase of a suspected ST-elevation myocardial infarction is lacking. PATIENTS AND METHODS: The Primary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysis-1 (PRAGUE-1) and PRAGUE-2 studies enrolled 1150 patients with ST-elevation acute myocardial infarction, in whom 625 coronary angiograms were performed within 2 h of the initial electrocardiogram. A simultaneous registry included an additional 379 coronary angiograms performed during the ST-elevation phase of a suspected myocardial infarction. Thus, a total of 1004 angiograms were retrospectively analyzed. A normal coronary angiogram was defined as one with the absence of any visible angiographic signs of atherosclerosis, thrombosis or spontaneous spasm. RESULTS: Normal coronary angiograms were obtained for 26 patients (2.6%). Among these, the diagnosis at discharge was a small myocardial infarction in seven patients (0.7%), acute (peri)myocarditis in five patients, dilated cardiomyopathy in four patients, hypertension with left ventricular hypertrophy in three patients, pulmonary embolism in two patients and misinterpretation of the electrocardiogram (ie, no cardiac disease) in five patients. Seven patients with small infarctions underwent angiography within 30 min to 90 min of complete relief of the signs of acute ischemia, and thus, angiograms during pain were not taken. None of the 898 patients catheterized during ongoing symptoms of ischemia had a normal coronary angiogram. Spontaneous coronary spasm as the only cause (without underlying coronary atherosclerosis) for the evolving infarction was not seen among these 898 patients. Thus, the causes of the seven small infarcts in patients with normal angiograms remain uncertain. CONCLUSIONS: The observed prevalence of normal coronary angiography in patients presenting with acute chest pain and ST elevations was 2.6%. Most of these cases were misdiagnoses, not infarctions. A normal angiogram during a biochemically confirmed infarction is extremely rare (0.7%) and was not seen during the ongoing symptoms of ischemia.

HISTORIQUE: On a déjà décrit des infarctus du myocarde avec surélévation du segment ST chez des patients aux artères coronaires saines, mais la coronarographie avait été effectuée après la phase aiguë de l’infarctus. Estil possible que la coronarographie n’ait pas été normale pendant la phase aiguë (on présumait généralement une thrombose coronaire transitoire ou des spasmes). On ne possède pas d’information sur la prévalence d’une coronarographie vraiment normale pendant la phase aiguë d’une présomption d'infarctus du myocarde avec surélévation du segment ST. PATIENTS ET MÉTHODOLOGIE: Dans le cadre des études PRAGUE-1 et PRAGUE-2 sur l’angioplastie primaire de patients transférés d’un hôpital général à une unité spécialisée de coronaropathie percutanée transluminale, on a enrôlé 1 150 patients ayant un infarctus aigu du myocarde avec surélévation du segment ST, chez qui 625 coronarographies ont été effectuées dans les deux heures suivant le premier électrocardiogramme. Un registre simultané contenait 379 autres coronarographies exécutées pendant la phase de surélévation du segment ST d’une présomption d’infarctus du myocarde. Ainsi, au total, 1 004 coronarographies ont fait l’objet d’une analyse rétrospective. Une coronarographie normale était définie comme un examen ne comportant aucun signe angiographique visible d’artériosclérose, de thrombose ou de spasme spontané. RÉSULTATS: On a obtenu des coronarographies normales auprès de 26 patients (2,6 %). De ce nombre, à leur congé, sept patients avaient un diagnostic de petit infarctus du myocarde (0,7 %) au congé, cinq patients, une (péri)myocardite, quatre patients, une myocardiopathie dilatée, trois patients, une hypertension accompagnée d’une hypertrophie ventriculaire gauche, deux patients, une embolie pulmonaire et cinq patients, une mauvaise interprétation de l’électrocardiogramme (c'est-à-dire, pas de maladie cardiaque). Les sept patients ayant un petit infarctus ont subi une angiographie de 30 à 90 minutes après le soulagement complet des signes d’ischémie aiguë, et non pendant la douleur. Aucun des 898 patients ayant subi un cathétérisme pendant des symptômes d’ischémie ne présentait de coronarographie normale. Chez ces 898 patients, on n’a observé aucun cas de spasme coronaire spontané (sans artériosclérose coronarienne sous-jacente) expliquant l’infarctus en évolution. Ainsi, les causes des petits infarctus chez les sept patients ayant une angiographie normale ne sont pas claires. CONCLUSIONS: On a observé une prévalence de 2,6 % de coronarographies normales chez les patients ayant des douleurs thoraciques aiguës et une surélévation du segment ST. La plupart de ces cas étaient des mauvais diagnostics et non des infarctus. Il est extrêmement rare de constater une coronarographie normale pendant un infarctus confirmé biologiquement (0,7 %), et on n’en a pas observé pendant les symptômes continus d’ischémie.

Charles University Prague Prague Czech Republic

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Sharifi M, Frohlich TG, Silverman IM. Myocardial infarction with angiographically normal coronary arteries. Chest. 1995;107:36–40. PubMed

Baumgart D, Liu F, Haude M, Gorge G, Ge J, Erbel R. Acute plaque rupture and myocardial stunning in patient with normal coronary arteriography. Lancet. 1995;346:193–4. PubMed

Christiaens L, Allal J, Martin Landragin I, et al. Normal coronary angiography. Survival and functional status at 6 years. Arch Mal Coeur Vaiss. 2000;93:1515–9. PubMed

Tun A, Khan IA. Myocardial infarction with normal coronary arteries: The pathologic and clinical perspectives. Angiology. 2001;52:299–304. PubMed

Da Costa A, Isaaz K, Faure E, Mourot S, Cerisier A, Lamaud M. Clinical characteristics, aetiological factors and long-term prognosis of myocardial infarction with an absolutely normal coronary angiogram; a 3-year follow-up study of 91 patients. Eur Heart J. 2001;22:1459–65. PubMed

Mansourati J, Da Costa A, Munier S, et al. Prevalence of factor V Leiden in patients with myocardial infartion and normal coronary angiography. Thromb Haemost. 2000;83:822–5. PubMed

Lagana B, Baratta L, Tubani L, Golluscio V, Delfino M, Rossi Fanelli F. Myocardial infarction with normal coronary arteries in a patient with primary antiphospholipid syndrome – Case report and literature review. Angiology. 2001;52:785–8. PubMed

Kyriakidis M, Androulakis A, Triposkiadis F, et al. Lack of a thrombotic tendency in patients with acute myocardial infarction and angiographically normal coronary arteries. Cardiology. 1995;86:22–4. PubMed

Russo C, Girelli D, Olivieri O, et al. G20210A prothrombin gene polymorphism and prothrombin activity in subjects with or without angiographically documented coronary artery disease. Circulation. 2001;103:2436–40. PubMed

Molzer G, Finsterer J, Krugluger W, Stanek G, Stollberger C. Possible causes of symptoms in suspected coronary heart disease but normal angiograms. Clin Cardiol. 2001;24:307–12. PubMed PMC

Widimsky P, Groch L, Zelizko M, Aschermann M, Bednar F, Suryapranata H. Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE study. Eur Heart J. 2000;21:823–31. PubMed

Widimsky P, Budesinsky T, Vorac D, et al. ‘PRAGUE’ Study Group Investigators. Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial – PRAGUE-2. Eur Heart J. 2003;24:94–104. PubMed

Fuster V, Badimon L, Badimon JJ, Chesebro JH. The pathogenesis of coronary artery disease and the acute coronary syndromes (1) N Engl J Med. 1992;326:242–50. PubMed

DeWood MA, Spores J, Notske R, et al. Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction. N Engl J Med. 1980;303:897–902. PubMed

Schwartz L, Bourasa MG. Evaluation of patients with chest pain and normal coronary angiograms. Arch Intern Med. 2001;161:1825–33. PubMed

Mohri M, Koyanagi M, Egashira K, et al. Angina pectoris caused by coronary microvascular spasm. Lancet. 1998;351:1165–9. PubMed

Fournier JA, Sanchez A, Quero J, et al. Myocardial infarction in men aged 40 years or less: A prospective clinical-angiographic study. Clin Cardiol. 1996;19:631–6. PubMed

Zimmerman FH, Cameron A, Fisher LD, Ng G. Myocardial infarction in young adults: Angiographic characterization, risk factors and prognosis (Coronary Artery Surgery Study Registry) J Am Coll Cardiol. 1995;26:654–61. PubMed

Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005;352:539–48. PubMed