New York Medical College Saint Mary's General Hospital and Saint Clare's Health, Florida
Disclosure(s): No relevant financial relationship(s) to disclose.
Introduction: Premature coronary artery disease (CAD) is defined as the occurrence of CAD before the age of 55 in men and 65 in women. It is a leading cause of early morbidity and mortality among individuals with a strong family history and untreated risk factors. Genetic predisposition plays a critical role in early atherosclerosis development.
Description: A male in his 40s with a family history (father and brother deceased before the age 55 from myocardial infarct) presented with 3-days of low-grade fever, myalgias, and chest pain. Past medical history included hyperlipidemia, with poor adherence to statin therapy. On initial evaluation, vital signs showed tachycardia HR 112 bpm and hypotension BP 85/50 mmHg, while physical exam was unremarkable. Electrocardiogram showed sinus tachycardia and initial troponin was elevated at 1500 ng/L. Viral prodrome, systemic inflammatory response, and hypotension favored sepsis and infectious myocarditis. However, significant family history of death from ischemic etiology raised suspicion for acute coronary syndrome (ACS). Fluid resuscitation, oral aspirin 324 mg, and atorvastatin 80 mg were immediately administered, followed by nitroglycerin, metoprolol 25 mg, and morphine once hemodynamically stable, with avoidance of non-steroidal anti-inflammatory drugs (NSAIDs). Serial ECG failed to demonstrate evidence of ischemia, while troponin rose within 12 hours, peaking at 5400 ng/L. Cardiac catheterization revealed a critical stenosis of the proximal left anterior descending (LAD) artery requiring a drug-eluting stent for coronary flow restoration.
Discussion: Premature CAD is often asymptomatic until a major cardiac event occurs, preventing its identification and prevention. Furthermore, chest pain with elevated cardiac biomarkers in young patients presenting with viral prodrome, is often presumed to be viral myocarditis, a common differential diagnosis. Premature CAD in first-degree relatives requires consideration—even when initial presentation suggests a non-ischemic etiology. Coronary angiography helps distinguish ACS from myocarditis and guide therapeutic decision-making. NSAIDs are commonly used in the treatment of myocarditis, but are contraindicated in myocardial infarction due to the increased risk of adverse cardiovascular events and mortality.
