Case Report

Discordance between the Clinical Presentation and Morphology of Myocardial Infarction in a Patient with Acute post-Hemorrhagic Anemia


While atherosclerotic plaque disruption remains the hallmark of type 1 myocardial infarction (T1MI), multiple other mechanisms provoking myocardial supply/demand mismatch (eg, anemia and tachyarrhythmias) are recognized as the potential causes of type 2 myocardial infarction (T2MI). In clinical practice, angiography is underutilized in patients with MI that have typical T2MI triggers, although the presence of these triggers and various forms of atherosclerotic coronary artery disease is not mutually exclusive. We describe a 70-year-old man that developed MI during hospitalization for gastrointestinal bleeding. He was treated conservatively without angiography due to posthemorrhagic anemia, which is a recognized T2MI trigger, and subsequently developed refractory cardiogenic shock. Autopsy revealed atherothrombosis, which is characteristic of T1MI.

1. Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio ALP, Caterina R De, Zimarino M, Roffi M, Kjeldsen K, Atar D, Kaski JC, Sechtem U, Tornvall P. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J 2017;38:143-153.
2. Vargas KG, Haller PM, Jäger B, Tscharre M, Binder RK, Mueller C, Lindahl B, Huber K. Variations on classification of main types of myocardial infarction: a systematic review and outcome meta-analysis. Clin Res Cardiol 2019;108:749-762.
3. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD, Mickley H, Crea F, Van de Werf F, Bucciarelli-Ducci C, Katus HA, Pinto FJ, Antman EM, Hamm CW, De Caterina R, Januzzi JL, Jr, Apple FS, Alonso Garcia MA, Underwood SR, Canty JM, Jr, Lyon AR, Devereaux PJ, Zamorano JL, Lindahl B, Weintraub WS, Newby LK, Virmani R, Vranckx P, Cutlip D, Gibbons RJ, Smith SC, Atar D, Luepker RV, Robertson RM, Bonow RO, Steg PG, O'Gara PT, Fox KAA. Fourth universal definition of myocardial infarction (2018). Kardiol Pol 2018;76:1383-1415.
4. Gupta S, Vaidya SR, Arora S, Bahekar A, Devarapally SR. Type 2 versus type 1 myocardial infarction: a comparison of clinical characteristics and outcomes with a meta-analysis of observational studies. Cardiovasc Diagn Ther 2017;7:348-358.
5. Morariu M, Hodas R, Benedek T, Benedek I, Opincariu D, Mester A, Chitu M, Kovacs I, Rezus C, Pasaroiu D, Mitra N, Georgescu D, Rezus E. Impact of inflammation-mediated response on pan-coronary plaque vulnerability, myocardial viability and ventricular remodeling in the postinfarction period - The VIABILITY study: protocol for a non-randomized prospective clinical study. Med 2019;98:e15194.
6. Raunio H, Rissanen V, Romppanen T, Jokinen Y, Rehnberg S, Helin M, Pyörälä K. Changes in the QRS complex and ST segment in transmural and subendocardial myocardial infarctions. A clinicopathologic study. Am Heart J 1979;98:176-184.
7. Sievers B, John B, Brandts B, Franken U, Bracht M Van, Trappe HJ. How reliable is electrocardiography in differentiating transmural from non-transmural myocardial infarction? A study with contrast magnetic resonance imaging as gold standard. Int J Cardiol 2004;97:417-423.
8. Bellotto F, Fagiuoli S, Pavei A, Gregory SA, Cati A, Silverj E, Plebani M, Zaninotto M, Mancuso T, Iliceto S. Anemia and ischemia: Myocardial injury in patients with gastrointestinal bleeding. Am J Med 2005;118:548-551.
9. Sudarsky D, Sudarsky M, Matezky S, Goldenberg I, Farcas A, Nikolsky E. Impact of early invasive approach on outcomes of patients with acute coronary syndrome and baseline anemia: analysis from the ACSIS registry. J Interv Cardiol 2015;28:315-325.
10. Roffi M, Patrono C, Collet J-P, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S; ESC Scientific Document Group. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016;37:267-315.
11. Carson JL, Guyatt G, Heddle NM, Grossman BJ, Cohn CS, Fung MK, Gernsheimer T, Holcomb JB, Kaplan LJ, Katz LM, Peterson N, Ramsey G, Rao S V, Roback JD, Shander A, Tobian AAR. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA - J Am Med Assoc 2016;316:2025-2035.
12. Mcquaid KR, Laine L. Systematic review and meta-analysis of adverse events of low-dose Aspirin and Clopidogrel in randomized controlled trials. Am J Med 2006;119:624-638.
IssueVol 15 No 3 (2020): J Teh Univ Heart Ctr QRcode
SectionCase Report(s)
Anemia Coronary angiography Myocardial infarction Myocardial ischemia Acute coronary syndrome

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Hoang T, Lazarev P, Maiskov V, Imad M, Kobalava Z. Discordance between the Clinical Presentation and Morphology of Myocardial Infarction in a Patient with Acute post-Hemorrhagic Anemia. J Tehran Heart Cent. 15(3):136-141.