Claxton, Benjamin B.

Henry, Christopher

Nahar, Ritu

Sun, George

Jefferson Digital Commons

Thomas Jefferson University Jefferson Digital Commons Division of Gastroenterology and Hepatology Faculty Papers Division of Gastroenterology and Hepatology 12-1-2022 Myocardial Infarction With Nonobstructive Coronary Arteries in New-onset Inflammatory Bowel Disease Benjamin B. Claxton Thomas Jefferson University George Sun Thomas Jefferson University Ritu Nahar Thomas Jefferson University Christopher Henry Thomas Jefferson University Follow this and additional works at: https://jdc.jefferson.edu/gastro_hepfp  Part of the Gastroenterology Commons Let us know how access to this document benefits you Recommended Citation Claxton, Benjamin B.; Sun, George; Nahar, Ritu; and Henry, Christopher, "Myocardial Infarction With Nonobstructive Coronary Arteries in New-onset Inflammatory Bowel Disease" (2022). Division of Gastroenterology and Hepatology Faculty Papers. Paper 86. https://jdc.jefferson.edu/gastro_hepfp/86 This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Division of Gastroenterology and Hepatology Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: JeffersonDigitalCommons@jefferson.edu. Inflammatory Bowel Diseases, 2022, XX, 1–2https://doi.org/10.1093/ibd/izac145Advance access publication 30 June 2022Case ReportsMyocardial Infarction With Nonobstructive Coronary Arteries in New-onset Inflammatory Bowel DiseaseBenjamin B. Claxton, MD MPH,*,  George Sun, BS,* Ritu Nahar, MD,* and Christopher Henry, MD**Division of Gastroenterology & Hepatology, Department of Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USAAddress correspondence to: Benjamin B. Claxton, MD, MPH, 1025 Walnut St. Suite 805, Philadelphia, PA 19107, USA (BClaxtonMD@gmail.com).Inflammatory bowel disease (IBD) is a systemic pro-inflamma-tory condition with rare cardiovascular extraintestinal manifestations. Increasing evidence links gut inflamma-tion and cardiovascular pathology, with myopericarditis encompassing approximately 70% of cases.1–3 Myocardial infarction with nonobstructive coronary arteries (MINOCA) has not been described in this population.4A 36-year-old man with a history of gastroesophageal re-flux disease and hypertension presented with a 10-day his-tory of fever, hematochezia, and abdominal pain. Negative history included no travel, suspect foods, or drug use. Family history was negative for IBD or cardiac disease. Exam was unremarkable except for mild abdominal tenderness in bi-lateral lower quadrants. Labs revealed elevated white blood cell count, C-reactive protein, and erythrocyte sedimenta-tion rate. Admission troponin and electrocardiogram (ECG) were normal.Computed tomography (CT) abdomen and pelvis revealed diffuse bowel wall thickening and associated mesenteric in-flammation of the entire colon. A stool infectious panel was negative. Sigmoidoscopy demonstrated diffuse continuous ulceration, friability, and granularity up to the splenic flexure (Figure 1A). Colon biopsies demonstrated diffuse, markedly active colitis. Although pathology had no evidence of chro-nicity, given a negative workup for infection or ischemia, no offending medications, no response to antibiotics, a char-acteristic endoscopic appearance, and a worsening clinical course that ultimately responded only to steroids, it was de-termined to be a diagnosis of early and new-onset ulcerative colitis.On day 4 of steroids, the patient noted severe chest pain. Electrocardiogram revealed new ST elevations (Figure 1B). High-sensitivity troponin was newly elevated to 1218 ng/L. Transthoracic echocardiogram (TTE) while having chest pain was normal and without wall motion abnormalities. A CT an-giogram (CTA) chest revealed no aortic dissection. A CTA of the coronary arteries showed no calcifications or wall motion abnormalities. Two days after his chest pain, he underwent cardiac magnetic resonance imaging (MRI). Imaging revealed transmural enhancement of the left ventricular apex with as-sociated akinesia—signs associated with infarct (Figure 1C). Notably, there was no sign of myocarditis. With new concern © The Author(s) 2022. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved.  For permissions, please e-mail: journals.permissions@oup.comReceived for publication: April 19, 2022. Editorial Decision: June 14, 2022Figure 1. A, Colon with ulceration, friability, and granularity. B, ECG with anterolateral, inferior 1-2mm ST segment elevation. C, Cardiac MR with transmural enhancement of the LV.Downloaded from https://academic.oup.com/ibdjournal/advance-article/doi/10.1093/ibd/izac145/6623438 by guest on 30 June 20222 Claxton et alfor MINOCA, the patient was treated for acute myocardial infarction.This case highlights a rare cardiac manifestation of IBD, unrelated to medication. Initial workup including ECG, TTE, and CTA were all without infarct territory or wall motion abnormalities. Computed tomography angiogram of the coronary arteries has a high negative predictive value for obstructive coronary artery disease.5 Therefore, MINOCA is the most accurate diagnosis. Given the sparsity of litera-ture regarding MINOCA, further investigation is needed to delineate the incidence of MINOCA and nonpharmacologic-associated cardiac events in IBD.Conflicts of InterestThe authors have no disclosures or conflicts of interest to delcare.References1. Patel RS, Rohit Reddy S, Llukmani A, et al. Cardiovascular manifestations in inflammatory bowel disease: a systematic re-view of the pathogenesis and management of pericarditis. Cureus. 2021;13(3):e14010.2. Singh S, Singh H, Loftus EV, Pardi DS. Risk of cerebrovascular accidents and ischemic heart disease in patients with inflamma-tory bowel disease: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2014;12(3):382-93.e1: quiz e22.3. Filimon AM, Negreanu L, Doca M, et al. Cardiovascular involve-ment in inflammatory bowel disease: dangerous liaisons. World J Gastroenterol. 2015;21(33):9688-9692.4. Caio G, Lungaro L, Caputo F, et al. Recurrent myocarditis in a pa-tient with active ulcerative colitis: a case report and review of the lit-erature. BMJ Open Gastroenterol. 2021;8:e000587. doi:10.1136/bmjgast-2020-000587.5. Roberts WT, Bax JJ, Davies LC. Cardiac CT and CT coronary angi-ography: technology and application. Heart. 2008;94(6):781-792.Downloaded from https://academic.oup.com/ibdjournal/advance-article/doi/10.1093/ibd/izac145/6623438 by guest on 30 June 2022

Myocardial Infarction With Nonobstructive Coronary Arteries in New-onset Inflammatory Bowel Disease

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Myocardial Infarction With Nonobstructive Coronary Arteries in New-onset Inflammatory Bowel Disease

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