Rate control or revascularisation in managing atrial fibrillation-induced myocardial infarction and heart failure?

Abstract

Acute myocardial infarction (MI) is a common and severe cardiovascular emergency that requires immediate treatment. Angina pectoris, which typically signals myocardial ischaemia, can appear in MI cases with myriad causes aside from coronary artery disease. However, not all MI patients benefit from invasive revascularisation therapy. We herein report a case involving a 78-year-old female patient with a complex medical history, including non-ST-segment elevation MI and coronary artery bypass grafting, who experienced recurrent chest pain. Instead of a direct result of coronary artery disease, her chest pain was later found to be primarily induced by atrial fibrillation (AF). Consequently, we shifted the focus of management to effective rate control for the AF after careful evaluation and achieved a satisfactory result. This case highlights the successful identification and timely application of intensive heart rate control management in an MI case induced by AF.

Keywords: Atrial fibrillation; Heart failure; Myocardial infarction; Rate control.

Fig. 1

A. Right anterior oblique and caudal views showing multiple subtotal occlusions and 90% stenosis in the left anterior descending artery; 80% stenosis in the proximal, calcification and ectasia in the middle, and 80–90% stenosis in the mid-distal circumflex artery, with collateral flow to the end of the right coronary artery 2 years previously. B. Left anterior oblique and caudal views of the left coronary lesions. C. 80% stenosis in the proximal, 80–95% stenosis in the mid-distal, and total occlusion in the distal right coronary artery (TIMI grade 0) 2 years previously. D. Unobstructed LIMA with a 75% local stenosis below the anastomosis (TIMI grade 3) 2 years previously. E. Electrocardiography of chest pain. F. Changes of creatine kinase isoenzyme (CKMB). G. Changes of troponin I. H. Right anterior oblique and caudal views showing total occlusion in the proximal left anterior descending artery and 90% stenosis in the proximal circumflex artery, which were worse than what was observed on the previous coronary angiography. I. Left anterior oblique and caudal views of total occlusion in the proximal left anterior descending artery and stenosis in the proximal circumflex artery. J. Left anterior oblique and cranial views showed 80% stenosis in the proximal, 80–95% stenosis in the mid-distal, and total occlusion in the distal right coronary artery (TIMI grade 0), which were similar to the previous coronary angiography. K. Unobstructed LIMA with a 75% local stenosis below the anastomosis (TIMI grade 3), which was similar to the previous coronary angiography.

Fig. 2

A timeline regarding findings and management. Blue boxes represent findings; Green boxes represent management; Orange boxes represent turning points in both findings and management. AF, atrial fibrillation; CAG, coronary angiography; CABG, coronary artery bypass grafting; EF, ejection fraction; LAD, left anterior descending artery; LCX, left circumflex artery; LIMA, left internal mammary artery; LVWMA, left ventricular wall motion abnormality; MR, mitral regurgitation; NSTEMI, non-ST-segment elevation myocardial infarction; RCA, right coronary artery; RVR, rapid ventricular rate; SVG, saphenous venous graft; TnI, troponin I. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)