Isolated Septal Artery Infarction in a Cocaine User

J INVASIVE CARDIOL 2021;33(11):E922.

Key words: cardiac magnetic resonance imaging, cocaine heart disease, coronary angiography

A 30-year-old patient who frequently uses cocaine presented to the emergency department with a 3-hour history of central chest pain and anterior ST-segment elevation on electrocardiogram. Emergent coronary angiography showed flush occlusion of the septal perforator (Figure 1A and Video 1) with retrograde filling from the right coronary artery (Figure 1B and Video 2). We opted for medical management as the pain was subsiding and the apparent infarct territory was small based on angiographic appearance. However, peak troponin T was subsequently elevated at 7538 ng/L. Cardiac magnetic resonance imaging demonstrated a transmural infarct involving 4 septal segments (Figure 2) resulting in moderate left ventricular systolic impairment (ejection fraction, 38%). The patient was discharged on dual-antiplatelet therapy, atorvastatin, ramipril, and bisoprolol. At follow-up, he was asymptomatic and his left ventricular ejection fraction improved to 50%.

Septal branches arising from the left anterior descending coronary artery supply the anterior interventricular septum in unison. In this unusual presentation of cocaine heart disease, occlusion of a single dominant septal perforator caused a large septal myocardial infarction, resulting in significant left ventricular impairment.