title: Computed tomography coronary angiography in patients with acute myocardial infarction and normal invasive coronary angiography.
abstract: BACKGROUND
  Three to five percent of patients with acute myocardial infarction (AMI) have normal coronary arteries on invasive coronary angiography (ICA). The aim of this study was to assess the presence and characteristics of atherosclerotic plaques on computed tomography coronary angiography (CTCA) and describe the clinical characteristics of this group of patients.
  
  
  METHODS
  This was a multicentre, prospective, descriptive study on CTCA evaluation in thirty patients fulfilling criteria for AMI and without visible coronary plaques on ICA. CTCA evaluation was performed head to head in consensus by two experienced observers blinded to baseline patient characteristics and ICA results. Analysis of plaque characteristics and plaque effect on the arterial lumen was performed. Coronary segments were visually scored for the presence of plaque. Seventeen segments were differentiated, according to a modified American Heart Association classification. Echocardiography performed according to routine during the initial hospitalisation was retrieved for analysis of wall motion abnormalities and left ventricular systolic function in most patients.
  
  
  RESULTS
  Twenty-five patients presented with non ST-elevation myocardial infarction (NSTEMI) and five with ST-elevation myocardial infarction (STEMI). Mean age was 60.2 years and 23/30 were women. The prevalence of risk factors of coronary artery disease (CAD) was low. In total, 452 coronary segments were analysed. Eighty percent (24/30) had completely normal coronary arteries and twenty percent (6/30) had coronary atherosclerosis on CTCA. In patients with atherosclerotic plaques, the median number of segments with plaque per patient was one. Echocardiography was normal in 4/22 patients based on normal global longitudinal strain (GLS) and normal wall motion score index (WMSI); 4/22 patients had normal GLS with pathological WMSI; 3/22 patients had pathological GLS and normal WMSI; 11/22 patients had pathological GLS and WMSI and among them we could identify 5 patients with a Takotsubo pattern on echo.
  
  
  CONCLUSIONS
  Despite a diagnosis of AMI, 80 % of patients with normal ICA showed no coronary plaques on CTCA. The remaining 20 % had only minimal non-obstructive atherosclerosis. Patients fulfilling clinical criteria for AMI but with completely normal ICA need further evaluation, suggestively with magnetic resonance imaging (MRI).
authors.affiliation: Department of Cardiology and Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden. georgios.panayi@regionostergotland.se.
authors.forename: Georgios
authors.initials: G
authors.lastname: Panayi
authors.affiliation: Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
authors.forename: Wouter G
authors.initials: WG
authors.lastname: Wieringa
authors.affiliation: Department of Cardiology and Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden.
authors.forename: Joakim
authors.initials: J
authors.lastname: Alfredsson
authors.affiliation: Department of Cardiology, Kalmar County Hospital and Linnæus University, Faculty of Health and Life Sciences, Kalmar, Sweden.
authors.forename: Jörg
authors.initials: J
authors.lastname: Carlsson
authors.affiliation: Department of Cardiology, County Hospital Ryhov, Jönköping and Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden.
authors.forename: Jan-Erik
authors.initials: JE
authors.lastname: Karlsson
authors.affiliation: Center for Medical Image Science and Visualization (CMIV), Linkoping University, Linkoping, Sweden.
authors.forename: Anders
authors.initials: A
authors.lastname: Persson
authors.affiliation: Department of Clinical Physiology and Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden.
authors.forename: Jan
authors.initials: J
authors.lastname: Engvall
authors.affiliation: Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
authors.forename: Gabija
authors.initials: G
authors.lastname: Pundziute
authors.affiliation: Department of Cardiology and Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden.
authors.forename: Eva
authors.initials: E
authors.lastname: Swahn
mesh_terms: D000328:Adult; D000368:Aged; D000072226:Computed Tomography Angiography; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000503:physiopathology; D003331:Coronary Vessels / Q000000981:diagnostic imaging*; D004452:Echocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography; D009203:Myocardial Infarction / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000503:physiopathology; D058226:Plaque, Atherosclerotic; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015203:Reproducibility of Results; D013548:Sweden; D013599:Systole; D016277:Ventricular Function, Left
keywords: Acute myocardial infarction; Computed tomography coronary angiography; MINCA; Normal coronary arteries