Can I publish a case report of a type 2 myocardial infarction triggered by nebulized medication with supraventricular tachycardia in an elderly patient after percutaneous coronary intervention in a critical‑care anesthesia journal?

Publishing a Type 2 MI Case Report in a Critical Care Anesthesia Journal

Yes, you can and should publish this case report in a critical care anesthesia journal, as it represents a clinically important intersection of perioperative medicine, critical care cardiology, and geriatric anesthesia that addresses a frequently misdiagnosed condition with significant management implications.

Why This Case Merits Publication

Clinical Significance and Educational Value

• Type 2 MI is substantially underrecognized and mismanaged, accounting for ≥15% of all MI cases nationally and 26–58% of emergency department presentations when troponin elevations are properly adjudicated, yet inter-observer agreement among cardiologists for distinguishing Type 2 MI from acute myocardial injury remains only modest 1

• Nebulization-triggered SVT causing Type 2 MI in a post-PCI geriatric patient represents a perfect teaching case because it demonstrates the critical diagnostic distinction: Type 2 MI results from myocardial oxygen supply-demand mismatch (in this case, tachyarrhythmia-induced) rather than acute coronary atherothrombosis, and this distinction fundamentally changes treatment 2, 1

• Tachyarrhythmias are the most common precipitant of Type 2 MI, accounting for approximately 55% of cases, making your case highly representative of a common clinical scenario that critical care and anesthesia providers encounter 1

Relevance to Critical Care Anesthesia

• Perioperative arrhythmias are well-recognized complications in the critical care setting, with both supraventricular and ventricular arrhythmias identified as independent risk factors for coronary events in the perioperative period 2

• The post-PCI geriatric population is at particularly high risk for supply-demand mismatch, as older patients have higher in-hospital and long-term mortality rates and enhanced clinical outcomes when complications are recognized early 2

• Nebulized medications (particularly beta-agonists) are frequently administered in critical care settings and can precipitate tachyarrhythmias, creating a direct link between anesthesia/critical care practice and Type 2 MI pathophysiology 1

Key Elements to Emphasize in Your Case Report

Diagnostic Criteria Documentation

Your case report should clearly demonstrate all three mandatory diagnostic components required by the European Society of Cardiology 1:

• Cardiac troponin elevation >99th percentile with a demonstrable rise-and-fall pattern on serial measurements (typically 0–1 h or 0–2 h intervals), as this dynamic change distinguishes acute injury from chronic elevation 1

• Objective evidence of myocardial ischemia, which may include ischemic symptoms (chest pain, dyspnea, diaphoresis), new ischemic ECG changes (ST-segment depression, T-wave inversion, transient ST elevation), or new regional wall-motion abnormalities on echocardiography or cardiac MRI 1

• Clear identification of SVT as the precipitating supply-demand mismatch, specifically triggered by nebulization in your geriatric post-PCI patient 1

Management Pitfalls to Highlight

The most critical teaching point is that aggressive antiplatelet therapy and anticoagulation are often inappropriate and may be contraindicated in Type 2 MI 1, 3:

• Your case should emphasize that the primary treatment for Type 2 MI is to identify and aggressively correct the underlying supply-demand mismatch condition (in this case, controlling the SVT), rather than activating the cardiac catheterization lab emergently 1, 3

• Emergent coronary angiography is NOT routinely indicated for Type 2 MI, as this wastes resources and exposes patients to unnecessary procedural risk 3

• The European Society of Cardiology guidelines specifically state that antithrombotic recommendations apply to NSTE-ACS (Type 1 MI without ST elevation), not Type 2 MI 3

Geriatric-Specific Considerations

• Geriatric patients with Type 2 MI are older, have more non-cardiovascular comorbidities, and fewer traditional atherosclerotic risk factors compared with Type 1 MI patients, making diagnostic accuracy even more critical 1

• The post-PCI status adds complexity, as Type 4a MI (peri-PCI MI) is defined by troponin elevation >5× 99th percentile in patients with normal baseline values, requiring careful differentiation from Type 2 MI 2

Specific Journal Fit

Why Critical Care Anesthesia Journals Are Appropriate

• Perioperative cardiovascular evaluation and arrhythmia management are core competencies for critical care anesthesiologists, as cardiac arrhythmias and conduction disturbances are not uncommon findings in the perioperative period, particularly in the elderly 2

• The case bridges multiple domains: nebulization practices (respiratory care), arrhythmia recognition and management (critical care cardiology), and post-procedural monitoring (anesthesia), making it highly relevant to the multidisciplinary critical care anesthesia audience 2

• Supraventricular arrhythmias can produce ischemia by increasing myocardial oxygen demand in patients with coronary disease, a concept that is fundamental to perioperative medicine and directly applicable to your case 2

Recommended Journal Targets

Consider submitting to journals such as:

• Journal of Cardiothoracic and Vascular Anesthesia (focuses on perioperative cardiac complications)
• Critical Care Medicine (publishes case reports on diagnostic and management challenges)
• Anesthesia & Analgesia (accepts case reports with significant educational value)
• Journal of Clinical Anesthesia (publishes case reports relevant to anesthesia practice)

Structuring Your Case Report

Essential Components to Include

Introduction: Emphasize that Type 2 MI accounts for a substantial proportion of troponin elevations in critical care settings, yet remains frequently misdiagnosed, leading to inappropriate treatment 1

Case Presentation: Document the temporal relationship between nebulization, SVT onset, troponin dynamics, and ischemic evidence, clearly distinguishing this from Type 1 MI or Type 4a (peri-PCI) MI 2, 1

Management: Detail how you corrected the underlying precipitant (SVT control) rather than pursuing emergent angiography or aggressive antiplatelet therapy 1, 3

Discussion:

• Explain the pathophysiology of tachyarrhythmia-induced Type 2 MI, noting that SVT increases myocardial oxygen demand while potentially reducing diastolic filling time and coronary perfusion 2, 1
• Highlight that the heart is particularly vulnerable to hemodynamically unstable arrhythmias early after MI, as demonstrated in research showing that supraventricular extrasystoles can initiate ventricular arrhythmias in 8% of acute MI patients 4
• Discuss the specific risks of nebulized beta-agonists in precipitating tachyarrhythmias in geriatric post-PCI patients 1

Conclusion: Emphasize that accurate Type 2 MI diagnosis prevents unnecessary invasive procedures, avoids potentially harmful antiplatelet/anticoagulation therapy, and directs treatment toward the actual precipitating condition 1, 3

Common Pitfalls to Avoid in Your Manuscript

• Do not conflate Type 2 MI with acute myocardial injury: Type 2 MI requires objective ischemic evidence, not just troponin elevation 1

• Do not suggest routine coronary angiography: Non-emergent angiography may be considered only if the patient develops cardiogenic shock, persistent ischemia despite treatment of the precipitant, or intermediate/high-risk findings on non-invasive testing 1, 3

• Do not recommend thrombolytics, as there is no thrombotic coronary occlusion to lyse 3

• Clearly differentiate from Type 4a MI: Your case occurred after PCI, so you must explicitly rule out procedural complication as the cause by demonstrating that troponin elevation was temporally related to SVT onset rather than the PCI procedure itself 2

Additional Considerations

Secondary Prevention Discussion

Your case report should address long-term management, as secondary prevention is frequently underutilized, with only 43% of Type 2 MI patients receiving aspirin and statin therapy at discharge despite high cardiovascular risk 1:

• High-intensity statin therapy should be initiated regardless of Type 2 MI etiology 1
• Beta-blockers should be used for symptomatic relief and long-term cardiovascular risk reduction when hemodynamically stable 1
• ACE inhibitors or ARBs should be considered for long-term cardiovascular risk reduction, particularly if hypertension, left ventricular dysfunction, heart failure, or diabetes mellitus is present 1

Follow-up and Disposition

Emphasize that outpatient cardiology follow-up is mandatory, as it is associated with higher rates of secondary-prevention medication initiation and may improve outcomes 1