A rare case of MINOCA secondary to infective endocarditis in a hemodialysis patient is reported, highlighting that 'the clinical presentation of infective endocarditis is atypical in patients undergoing dialysis, especially in the presence of other life-threatening conditions,' and that 'early multimodal imaging and multidisciplinary collaboration are essential for the timely diagnosis and management.'
Key Findings
Results
A 52-year-old male on long-term hemodialysis via tunneled-cuffed catheter presented with acute chest pain and was found to have MINOCA secondary to infective endocarditis.
The patient had a 4-hour history of persistent acute chest distress and pain that developed immediately after defecation, accompanied by shortness of breath and profound sweating.
Initial ECG showed ST-segment depression and T-wave alterations in inferior leads (II, III, and aVF), and troponin I levels were elevated, raising suspicion of acute myocardial infarction.
Emergency coronary angiography revealed no significant obstructive coronary artery disease: 20-30% stenosis of the middle segment of the anterior descending artery, 30-40% stenosis of the circumflex artery, and no significant stenosis of the left main or right coronary artery.
The constellation of findings led to the diagnosis of MINOCA secondary to IE in the context of uremia and long-term hemodialysis.
Results
Cardiac ultrasonography revealed aortic valve vegetation with massive and moderate aortic valve regurgitation, consistent with infective endocarditis.
Cardiac ultrasonography showed hyperechogenicity of the aortic valve, suggesting the presence of vegetation.
Echocardiographic findings demonstrated massive and moderate aortic valve regurgitation.
The irregular appearance of the aortic valve was also noted on emergency coronary angiography.
These imaging findings were instrumental in establishing the diagnosis of IE as the underlying cause of MINOCA.
Results
Laboratory findings demonstrated systemic infection with elevated inflammatory markers consistent with infective endocarditis.
Laboratory results revealed an increased percentage of white blood cells and neutrophils.
C-reactive protein (CRP) was elevated.
Troponin I was elevated, consistent with myocardial injury.
These findings, combined with imaging, supported the diagnosis of IE-related MINOCA.
Results
The patient was successfully treated with broad-spectrum antibiotics followed by surgical aortic valve replacement with cardiopulmonary bypass.
Treatment was initiated with broad-spectrum antibiotics upon suspicion of MINOCA secondary to IE.
The patient underwent mechanical aortic valve replacement with cardiopulmonary bypass due to echocardiographic findings of massive and moderate aortic valve regurgitation.
Following surgery, inflammatory markers and white blood cell counts significantly decreased, serum troponin decreased, and ST-T changes on ECG significantly recovered.
The patient was discharged with anti-infection therapy, cardiac strengthening, blood purification, and nutritional support.
Background
Infective endocarditis is relatively common among uremia patients undergoing long-term hemodialysis due to frequent vascular access procedures and impaired immune function.
The authors note that IE 'results from the combined effects of multiple factors, such as frequent vascular access procedures and impaired immune system function.'
IE is described as 'relatively common among patients with uremia undergoing long-term hemodialysis.'
The patient's tunneled-cuffed catheter use for hemodialysis was identified as a relevant risk factor.
The clinical presentation of IE is noted to be atypical in dialysis patients, particularly when other life-threatening conditions are present.
Conclusions
Early multimodal imaging and multidisciplinary collaboration were identified as essential for timely diagnosis and management of concurrent MINOCA and IE.
The authors conclude that 'early multimodal imaging and multidisciplinary collaboration are essential for the timely diagnosis and management of MINOCA and IE.'
Cardiac ultrasonography played a key diagnostic role in identifying aortic valve vegetation when coronary angiography alone showed non-obstructive disease.
The case illustrates the risk of misdiagnosis when atypical presentations of IE overlap with other acute conditions such as AMI.
The paper includes a literature review component to contextualize this rare clinical scenario.
What This Means
This research describes a rare and complex case of a 52-year-old man on long-term kidney dialysis who came to the hospital with severe chest pain and was initially suspected of having a heart attack. Standard heart attack tests — including an ECG and elevated heart injury markers in the blood — supported that suspicion. However, emergency imaging of the coronary arteries showed no significant blockages, meaning the patient had what is called a 'myocardial infarction with non-obstructive coronary arteries' (MINOCA). Further investigation, including heart ultrasound, revealed that the real culprit was an infection on the heart's aortic valve (infective endocarditis, or IE), which had caused a growth (vegetation) on the valve and was leading to severe valve leakage and heart muscle injury.
The patient was treated first with broad-spectrum antibiotics, then underwent open-heart surgery to replace the damaged aortic valve with a mechanical one. After surgery, his infection markers, heart injury markers, and ECG abnormalities all improved significantly, and he was discharged with a comprehensive treatment plan. This case highlights that dialysis patients are at higher risk for heart valve infections because they require frequent access to their bloodstream and have weakened immune systems, but the symptoms of such infections can be misleading and may mimic or trigger other heart emergencies.
This research suggests that when dialysis patients present with apparent heart attacks but no blocked coronary arteries, doctors should consider heart valve infection as a potential underlying cause. Using multiple imaging tools — particularly heart ultrasound — alongside standard cardiac testing, and coordinating care across multiple medical specialties, may be critical to reaching the correct diagnosis quickly and avoiding potentially life-threatening delays in appropriate treatment.
Cheng L, Li L. (2026). Infective endocarditis presenting with myocardial infarction with non-obstructive coronary arteries: A case report and literature review.. Medicine. https://doi.org/10.1097/MD.0000000000050707