Acute myocardial infarction

Case contributed by Julian L. Wichmann


Acute chest pain, elevated cardiac enzymes but also elevated d-dimers, therefore triple-rule-out CT was performed.

Patient Data

Age: 80 years
Gender: Male

CT angiography


15 mg of metoprolol and 2 sublingual sprays of glyceryl trinitrate (nitroglycerin) were administered before the scan.

There is an occlusion of the middle segment of the LAD resulting in an anterior wall infarction with consecutive akinesia and microvascular obstruction.

There is also stenosis of the proximal part of the D2 branch of the LAD.

There is infarct-related right-sided pleural effusion and alveolar edema.


Invasive coronary angiography confirms the diagnosis and also demonstrates narrowing of the D2 branch.

Case Discussion

This case demonstrates acute myocardial infarction with resulting perfusion deficits with microvascular obstruction. Invasive coronary angiography images confirmed the diagnosis.

Triple-rule-out computed tomography is useful for diagnosing or ruling out the major life-threatening thoracic pathologies: aortic dissection, pulmonary embolism and myocardial infarction, especially since D-dimer levels can be elevated due to various other reasons as malignancies, infection or leukemia.

This patient presented with chest pain, elevated D-dimer levels and shortness of breath. The treating cardiologist suspected acute myocardial infarction, but requested a CT angiography scan to rule out pulmonary embolism. After diagnosis, the patient was immediately transferred to the catheterization lab, where multiple stents were placed.

Microvascular obstruction, which is present in this case, is known to be a significant predictor of major adverse cardiac events. Unfortunately, this was also true in this case, and the patient died a week later from cardiac arrest.

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