Myocardial ischemia in Wegener's granulomatosis: coronary atherosclerosis versus vasculitis

Abstract

Wegener's granulomatosis (WG) is one of the most common small- and medium-sized necrotizing vasculitides that mainly affects the upper and lower respiratory tract and the kidneys. Cardiac manifestations in WG are relatively rare, and their role and place among different causes of mortality remain largely unknown. Substantially increased number of reports describing involvement of all structures of the heart, which underlie conduction disturbances, valvular disease, ischemic heart disease and other potentially serious conditions, underscores importance of comprehensive cardiovascular investigations and monitoring of patients with WG. The majority of previous reports and our current observation distinguish coronary vasculitis and thrombosis as a cause of myocardial ischemia and cardiovascular co-morbidities in WG. It seems plausible that inflammatory processes in this disease, like in some other systemic vasculitidies, do not predispose to accelerated atherogenesis. However, characteristic small- and medium-sized vasculitis still can manifest as myocardial ischemia and infarction. We overview diverse cardiac manifestations and present our own rare case of angina in the oligosymptomatic debut of WG. Importantly, in this case, coronarography failed to reveal atherosclerotic disease or thrombotic occlusion. However, magnetic resonance imaging (MRI) with adenosine test revealed subendocardial ischemia. As a result of immunosuppressive therapy with a steroid and cyclophosphamide, myocardial ischemia disappeared.

Keywords: Atherosclerosis; Coronary arteries; Vasculitis.; Wegener’s granulomatosis.

Fig. (1)

ECG on admission. Regular sinus rhythm, heart axis deviation to the left, ST-T changes of ischemic origin in I, aVL and V3-6.

Fig. (2)

Magnetic resonance imaging (MRI). Ascending and thoracic aorta (A), both ventricles of the heart (B) without pathological changes. After adenosine infusion, endocardial ischemia in the septum and posterior wall of the left ventricle was detected (C).

Fig. (3)

Coronaroangiography. Left (A, B) and right coronary arteries (B, C, D) without visible pathological changes.