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Correspondence

Recurrent acute coronary syndrome with Takayasu arteritis

Li, Hui; Sun, Fucheng

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doi: 10.3760/cma.j.issn.0366-6999.20131716
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To the editor: Takayasu arteritis (TA) is a rare form of large vessel vasculitis, predominantly affecting the aorta and its main branches.

In March 2012, a 59-year-old Chinese woman with 33 years of TA, was admitted to our Emergency Department for acute coronary syndrome. Serum cTnI was 0.631 ng/ml, electrocardiogram showed extensive T wave inversion. On physical examination, we found weak pulse on both sides of radial artery and femoral artery, bruits over right subclavian artery. Blood pressure of right arm was 70/58 mmHg (1 mmHg=0.133 kPa), and 68/58 mmHg for the left.

Since a fever in 1979, the patient had been felt weak, fatigue, dizziness, short of breath gradually. Two years later, she was diagnosed with Takayasu arteritis (conditions not clear at that time), and treated with prednisone, but stopped soon because of abnormal liver function. After then her symptom had been stabilized, until 1993 when she had the first heart attack but only treated with medicine. And in 2009, she was diagnosed having non-ST segment elevation myocardial infarction. Computed tomography angiography (CTA) of coronary artery at that time demonstrated severe stenosis of left main coronary (Figure 1A-1C). CTA of thoracic aorta showed critical stenosis of bilateral proximal subclavian arteries, occlusion of left internal carotid artery (Figure 1D-1F). During hospital admission at this time, we did CTA of abdominal aorta, which showed occlusion of infrarenal abdominal aorta and right common iliac artery, a lot of collateral vascularization to the lower extremities, and severe stenosis of right renal artery (Figure 1G).

Figure 1.
Figure 1.:
Image data. A: Left main artery and left descending artery. B: Left circumflex artery. C: Right coronary artery. D: Right proximal subclavian artery. E: Left internal carotid artery. F: Left proximal subclavian artery. G: Infrarenal abdominal aorta and right common iliac artery.

According to the criteria of the American College of Rheumatology,1 including onset age, symptoms, signs, and angiographic findings related to the involvement of the aorta and its major branches, the diagnosis of TA is definite. Aortic involvement is common in TA, and is usually seen as an irregular outline or a stenosing lesion, but total aortic occlusion is quite rare, the incidence was reported only 2.7%.2 For this patient, the treatment was quite difficult. We found no appropriate route to perform coronary angiography or intervention. The cardiac surgeon refused to do the heart surgery for the patient's bad condition. At last she got only medicine treatment, and was prescribed with aspirin, clopidogrel and statin, but no ACEI and β-blocker for no way to achieve the level of real blood pressure.

REFERENCES

1. Arend WP, Michel BA, Bloch DA, Hunder GG, Calabrese LH, Edworthy SM, et al. The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum 1990; 33: 1129-1134.
2. Sharma S, Rajani M. Aortic occlusion in nonspecific aorta arteritis (Takayasu disease): incidence and spectrum of involvement. Australas Radiol 1993; 37: 57-59.
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