Introduction: Acute myocardial infarction is the le-ading cause of cardiovascular death and occurs most frequently as a result of atherosclerosis. Dyslipidemia is one of the major cardiovascular risk factors. A lack of early diagnosis and treatment, as well as other potential non-cardiovascular pathologies that modify the lipid metabolism can have disastrous consequences, even among young patients.
Case presentation: A 48 years old female patient, acti-ve smoker, at menopause for 3 years, without any prior history of cardiovascular disease, is admitted for seve-re retrosternal chest pain with sudden onset at rest 3 hours before the presentation. The pain is associated with nausea and dizziness and has no spontaneous re-lief factors. The patient reports multiple anterior chest pain episodes in the last 6 months, that occured during physical activity and has progressively increased in in-tensity during this period of time. She also complained of increased fatigue and weight gain with low appetite during the last year. On clinical examination, the patient presents grade 1 obesity and facial edema, without pulmonary or syste-mic congestion, her skin was pale, BP 145/80 mmHg, low HR (45/min), regular pulse, and no cardiac mur-murs. The thyroid gland is enlarged and presents incre-ased firmness. ECG-sinus rhythm, HR 44/min, ST elevation in the DII, DIII, aVF leads. Based on the clinical presentation and ECG, the diagnosis of acute inferior wall myocar-dial infarction Killip 1 is established. The myocardial enzyme markers (TnI, CK-MB) were negative at the first determination. Significant changes of the lipid profile, with marked hypercholesterolemia and hypertriglyceridemia (total cholesterol 420 mg/dl, LDL cholesterol 300 mg/dl, triglycerides 450 mg/dl) are noticed. Thyroid function tests are also outside of the normal range: FT4 is low and TSH is 20 times higher than the normal value, so severe hypothyroidism was present. Echocardiography- inferior and posterior walls aki-nesis with systolic traction of the posterior mitral lea-flet and moderate mitral insufficiency. LVEF 40%. The emergency coronary angiogram reveals a com-plete occlusion of the mid right coronary artery and a critical stenosis of the proximal left anterior descending coronary artery. Primary angioplasty is performed, a drug eluting stent being implanted in the medium right coronary artery with a good final result. Subsequently, the hospital stay is uneventful, pain relief and complete ST elevation remission being noti-ced 20 minutes after coronary angioplasty. During day 4 of the admission, coronary angioplasty with a drug eluting stent is performed in the proximal left anteri-or descending artery. Treatment with dual antiplatelet therapy, a beta blocker, angiotensin-converting enzyme inhibitor, high dose of statin and fibrate was administered. The endocrinologist establishes the diagnosis of myxedema and secondary dyslipidemia, for which spe-cific oral treatment is introduced. Thyroid ultrasound reveals a nodular enlargement of the gland, without any signs of neoplastic changes. The long-term prognostic is favorable if the risk fac-tors are properly managed.
The particularity of the case: Particular in this case is the onset of the acute transmural myocardial infarcti-on, with advanced coronary heart disease, in a young woman, in the context of accelerated atherosclerosis, mainly caused by the undiagnosed thyroid pathology. Conclusion: This case draws attention to the importan-ce of controlling cardiovascular risk factors at any age, by constantly monitoring the lipid profile and early ma-nagement of its alteration, by evaluating the presence of comorbidities that increase the risk of atherosclerosis (eg hypothyroidism, diabetes mellitus) and by reducing high-risk behaviors (eg smoking, sedentary lifestyle).