THU0592 INSIDIOUS CORONARY ARTERY DISEASE IN A YOUNG PATIENT WITH POLYARTERITIS NODOSA: A CASE REPORT AND REVIEW OF LITERATURE
Authors: H. Huang, Z. Zhang
Journal: Annals of the Rheumatic Diseases (2020)

Background: Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis that typically affects medium-sized muscular arteries, with occasional involvement of small muscular arteries[1]. Although overt myocardial infarction is uncommon, myocardial ischemia may result from narrowing or occlusion of the coronary arteries[2]. Objectives: Herein, we report a case with 7-year’s history of PAN and unstable angina pectoris due to coronary occlusions of the three main arteries. We also reviewed the literatures regarding coronary artery involvement in PAN. Methods: A 22-year-old Chinese man who presented with chest pain lasting for a few minutes and then subsiding spontaneously for 1 month was admitted to our hospital. He was diagnosed as PAN 7 years ago and during 7-years’ follow-up, he has been in stable condition, without any discomfort or abnormal laboratory findings. In December 2019, he suffered from chest distress accompanied by retrosternal pain, with frequency of about 2-3 times a week. His symptoms were gradually aggravating with dyspnea at night. Results: Coronary computed tomography angiography showed diffuse coronary stenosis (Fig. 1). Further coronary angiography revealed a slight plaque infiltration of the left main coronary artery, and occlusion of all the three major coronary arteries, as well as multiple coronary aneurysms. 95% stenosis of the obtuse margin branch artery was also found and a stent was then implanted (Fig. 2). Prednisone 50mg/day and methotrexate 15mg/week were reinitiated, in combination with anti-anginal medications including aspirin and statin. Fig. 1 Coronary computed tomography angiography found diffuse coronary stenosis. Fig. 2 Coronary angiography. (a) A 50% stenosis followed by aneurysmal change of the proximal end of left anterior descending (LAD) artery, and totally occluded from the middle segment; A aneurysmal change of the initial part of left circumflex artery (LCX) and then totally occluded (dotted line); A 95% stenosis obtuse margin branch. (b) A totally occluded right coronary artery (dotted line). (c) Final appearance of the LCX after stent implantation. After we reviewed all the English literatures reporting cardiac involvements in adults with PAN from 1990 to 2019, a total of 34 patients from 32 articles were identified. 25 (73.5%) patients were admitted to hospital due to acute coronary syndromes manifesting as chest pain or dyspnea. Coronary stenosis or occlusions were most common on imaging or autopsy. Most of the patients had more than one vessel involved, of whom 7 patients showed evidence of triple vessel lesions. Aneurysm was also common in these patients, especially multiple aneurysms. Spontaneous coronary artery dissections were rare in PAN patients. Most patients received glucocorticoid, and/or immunosuppressant therapy, including cyclophosphamide and azathioprine, with or without invasive operations. 15 patients died from cardiopulmonary arrest, the most frequent cause being death, and 15 patients were stable without symptoms after treatment. Conclusion: We report a young PAN patient with insidious stenosis of three main coronary arteries under the circumstance of stable disease activity for years. This reminds us of the necessity of assessing heart, probably other organs as well, in PAN patients even though their acute phase reactants in serum are normal. But how often to do the screening and which screening examination should be done, remain to be further investigated. References: [1]Jennette, J.C., et al., 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum, 2013. 65 (1): p. 1-11. [2]Kastner, D., M. Gaffney, and T. Tak, Polyarteritis nodosa and myocardial infarction. Can J Cardiol, 2000. 16 (4): p. 515-8. Disclosure of Interests: None declared