Background: Takayasu arteritis (TA), also known as pulseless disease, is a chronic idiopathic rare granulomatous vasculitis of large arteries and its branches. TA can be classified into 2 phases: 1) systemic phase and 2) occlusive phase. The systemic phase commonly presents with constitutional symptoms of inflammation, followed by symptoms caused by narrowed vessels in the systemic phase. Clinical manifestations of TA vary along the clinical course, ranging from fever, chest pain, limb claudication, decreased or absence of arterial pulsation to ischemic symptoms. Although, the main entity to the diagnosis is imaging to determine stenosis of major vessels. Case Summary: A 26-year-old male was referred to our center with typical chest pain 11 hours prior to admission, without a previous history of myocardial infarction. The patient also had intermittent claudication, with a history of amputation in the right toe 1 year prior. Currently, the patient consumes alcohol, in addition to being an active smoker for 10 years. ECG study revealed a vast anterior STEMI. Systolic blood pressure between arms showed a difference of more than 10 mmHg. The patient had a high ESR (34 mm/hour), elevated transaminase enzymes (AST 694 IU/L, ALT 109 IU/L), high inflammatory markers (CRP 12.6 mg/L, LED 34mm/hr), and elevated troponin I (32.04 ng/mL). Chest X-Ray displays enlarged heart size with 55% CTR. Echocardiography was performed and showed an HFrEF (EF by Teich 38%), LV dilatation, and severe hypokinetic of anterior to lateral wall of LV. Doppler Ultrasound (DUS) found no colour coded on the right popliteal artery, right dorsalis pedis artery and no flow from left deep femoral artery, left common femoral artery, left anterior tibial artery, and left posterior tibial artery, suggesting a peripheral artery disease (PAD) of both lower extremities. DUS also revealed a small abdominal aorta diameter (1.4 cm). Following findings highly suggest the probability of TA. Besides PPCI stent in proximal-mod LAD, this patient also received loop diuretic, anticoagulant, dual antiplatelet, antihypertension, statin, and beta-blocker. Antiinflammation was not yet given because the real confirmation of TA diagnosis needed to be done. Discussion: Takayasu arteritis is a rare form of vasculitis. Delays of TA diagnosis may result in significant morbidity, hence proper assessment is pivotal. From Ishikawa criteria, this case consists of one major criteria, that is more than one month duration of clinical signs and symptoms, following two minor criterias, which are high ESR and coronary artery lesion, suggesting high probability of TA. From American College of Rheumatology (ACR) criteria, this case is including presence of claudication of extremities, systolic blood pressure difference of >10 mmHg, and narrowing of aorta as arteriogram abnormality, highly suggesting TA diagnosis. Both criteria include age <40 years old as one of the criteria. Besides therapy for the cardiovascular symptoms, antiinflammation is also needed to treat the underlying cause.

Takayasu Arteritis

STEMI

Peripheral Artery Disease

Heart Failure

Vascular Inflammation