Takayasu's Arteritis Presenting as Acute STEMI

An 18-year-old man with past medical history of secondary arterial hypertension diagnosed at age 15 presented with an abdominal magnetic resonance imaging (MRI) that exhibited left renal artery stenosis. He received management with propranolol with complete improvement. However, he subsequently consulted due to oppressive chest pain. Electrocardiogram displayed anterolateral ST-segment elevation myocardial infarction (STEMI). Hours after admission, he presented with a 10-minute cardiorespiratory arrest with pulseless ventricular tachycardia, requiring defibrillation to return to sinus rhythm. After the episode, he underwent emergent coronary angiography that diagnosed a saccular aneurysm of the left main coronary artery with ostial occlusion of the left anterior descending artery, in addition to a 70% severe lesion in the atrioventricular branch that originated from the circumflex artery (Figure, Video). Stabilization was achieved by an intra-aortic balloon pump.

A week later, he underwent cardiovascular surgery with an autologous pericardium endo-aortic patch to correct the defect, and coronary artery bypass graft surgery (saphenous to obtuse marginal 1, due to a very thin internal mammary artery that originated from a subclavian artery with vasculitis). Studies revealed elevation of the C-reactive protein, erythrocyte sedimentation rate, and complement, with the rest of the autoimmune profile within normal limits. A total body MRI exhibited stenosis of the extracranial internal carotid arteries (mostly the left one), left renal artery stenosis, and irregularities of the left subclavian artery — namely, of the descending thoracic aorta and of the abdominal aorta — that also had late enhancement suggesting active inflammation. All the above led to the diagnosis of a large-vessel vasculitis (Takayasu's arteritis). Management with steroid pulses and then a maintenance schedule with oral steroids and methotrexate improved the patient’s clinical picture.

Affiliations and Disclosures

From ¹AUNA Clínica Las Américas, Medellín, Antioquia, Colombia; ²Hospital San Vicente Fundación, Rionegro, Antioquia, Colombia.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence:  Laura Duque-González, MD, Cl. 34 #43-66, San Diego Mall, North Tower, 11th floor, Medellín, Antioquia, Colombia. Email: duqueglaura@gmail.com