ST-elevation myocardial infarction caused by plaque erosion in a 23-year-old male

Intravascular imaging techniques, such as optical frequency domain imaging (OFDI), are essential for understanding the pathophysiology of acute coronary syndrome, including plaque rupture, plaque erosion, and calcified nodules. Plaque erosion is more common in younger patients than plaque rupture. We report a case of ST-elevation myocardial infarction caused by plaque erosion in a 23-year-old man. The patient presented with sudden-onset chest pain at work. Electrocardiography revealed ST-segment elevations in leads I, aVL, and V2–4. Coronary angiography identified thrombus formation in the left anterior descending artery (LAD) and total occlusion of the diagonal branch (D1). OFDI confirmed thrombus and plaque erosion in the LAD. Thrombus aspiration of the D1 restored thrombolysis in myocardial infarction grade 3 flow. Aspirated thrombus analysis revealed evidence of platelet aggregation and fibrin deposition. The absence of atherosclerosis or calcification on OFDI and a negative ergonovine provocation test supported the diagnosis of plaque erosion. Follow-up OFDI after three months showed thrombus resolution and residual fibrous plaque. This case highlights the role of OFDI in evaluating vascular characteristics during acute and chronic phases, enabling a precise diagnosis of plaque erosion.

Learning objective

We report a case of ST-elevation myocardial infarction caused by plaque erosion in a 23-year-old patient. This case is noteworthy as it likely represents the first instance of thrombus originating from the left anterior descending artery and embolizing to the diagonal branch. The use of optical frequency domain imaging during both the acute and chronic phases allowed for precise assessment of the pathology.