Coronary Angiography is the Next Best Step
This patient requires urgent coronary angiography to evaluate for acute myocardial infarction, as the combination of elevated troponin (0.263 ng/mL) and ST elevations on ECG indicates acute myocardial injury that must be presumed to be from coronary artery disease until proven otherwise. 1
Clinical Reasoning
This patient presents with objective evidence of acute myocardial injury in the preoperative setting:
- Elevated cardiac troponin (0.263 ng/mL) combined with ST elevations on ECG meets diagnostic criteria for acute myocardial infarction and represents a high-risk scenario requiring urgent intervention 1, 2
- The recent viral illness (cough, nasal congestion, myalgias 2 weeks ago) raises the possibility of viral myocarditis, but ST elevations with troponin elevation mandate exclusion of obstructive coronary disease first 1, 3
- Normal CK-MB does not exclude myocardial infarction, as troponin is the preferred and more sensitive biomarker 2
- The preserved ejection fraction and normal ventricular dimensions on echocardiogram do not rule out acute coronary syndrome 1
Why Coronary Angiography is Required
The European Society of Cardiology identifies this patient as high-risk based on:
- Elevated troponin levels 1
- Dynamic ST-segment changes (ST elevation) 1
- These high-risk features mandate coronary angiography within 48 hours, or sooner if severe ongoing ischemia is present 1
Coronary angiography will:
- Identify obstructive coronary artery disease requiring revascularization (type 1 MI from plaque rupture/thrombosis) 4
- Rule out coronary disease if arteries are normal, allowing consideration of alternative diagnoses like myocarditis 5, 3
- Guide appropriate medical therapy based on findings 1
Why Other Options Are Inappropriate
Endomyocardial biopsy (Option A) would only be considered after coronary angiography demonstrates normal coronary arteries and myocarditis remains the leading diagnosis 5, 3
Transesophageal echocardiogram (Option B) does not evaluate coronary anatomy and would not change acute management in a patient with troponin elevation and ST elevations 1
Exercise stress testing (Option C) is absolutely contraindicated in a patient with acute troponin elevation and ST-segment changes, as this represents ongoing acute myocardial injury 1, 2
Critical Management Points
- Type 1 MI (acute coronary syndrome from plaque rupture) causes <5% of perioperative troponin elevations, but when ST elevations are present with elevated troponin, this diagnosis must be excluded first 4
- While troponin elevation can occur from non-coronary causes (myocarditis, pulmonary embolism, sepsis, renal failure), the presence of ST elevations significantly increases the likelihood of acute coronary syndrome 1, 3
- Normal coronary anatomy on catheterization would then shift the diagnosis to non-obstructive myocardial injury (likely viral myocarditis given the recent illness), and endomyocardial biopsy could be considered at that point 5
Implications for Surgery
The planned elective rotator cuff repair must be postponed until the cardiac evaluation is complete and the patient is stabilized, as proceeding with surgery in the setting of acute myocardial injury would carry unacceptable mortality risk 4