P35 cardiac magnetic resonance: promising solution in clinical dilemma

Abstract There are many clinical conditions in which symptoms and signs can overlap, resulting in a real "clinical dilemma". Differential diagnosis is essential for identifying the pathology affecting a patient and consequently making the best therapeutic decisions. Herein we report a case of a young patient, with strong smoking habit, who looked for medical attention after experiencing chest pain, associated to upper airways inflammation. EKG revealed ischemic abnormalities, echocardiography showed a preserved ejection fraction (EF: 55%) and global cardiac contractility, although akinesia of the mid–segment of the inferolateral wall, and the presence of a mild inferolateral pericardial effusion. A concomitant increase in myocardial necrosis enzymes and inflammatory markers was observed in blood tests, but the coronarography showed undamaged coronary arteries. This clinical picture characterized by the young age of the patient, by the intercurrent inflammatory event, by the presence of pericardial rubbing on physical examination, by the evidence of echocardiographic end EKG anomalies in the absence of documentable epicardial lesions and by the complete symptomatic remission after anti – inflammatory therapy with acetylsalicylic acid and Colchicine was highly suggestive of pseudoinfarct–presenting myopericarditis. To confirm such diagnosis, cardiac magnetic resonance (CMR) was requested, unexpectedly, it showed oedema on the mid–basal inferolateral T2–weighted STIR sequences, but also microvascular obstruction (MVO) on early EGE contrastographic sequences mid–basal inferolateral site, and finally evidence of transmural fibrosis in the same site to the DE sequences resulting in pathognomonic lesions for acute ischemia in absence of epicardial coronaropathy. CMR imaging, which is able to analyse cardiac structure and function and simultaneously provide tissue characterization, has been an essential investigation for the diagnosis of MINOCA, as CMR can readily pinpoint many conditions responsible for myocardial damage and allow pathological discrimination of patients. Our patient‘s final diagnosis was “STEMI, MINOCA, and concomitant pericarditis” implying a consequent therapeutic modification, introducing DAPT. Making differential diagnosis in similar clinical conditions characterized by overlapping presentations, allows the use of personalized therapeutic strategies for each patient and better final results.