Left Main Coronary Artery Dissection in Pediatric Sport-Related Chest Trauma
Jose Diaz-MironPatrick A. DillonArun SainiDavid T. BalzerJasvindar SinghNikoleta S. KolovosJennifer G. DuncanMartin S. Keller
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Cardiac biomarkers such as troponins and natriuretic peptides have become important in the diagnostic treatment of acute coronary syndrome and heart failure. With the appearance of high sensitive troponins, after intense physical activity in some athletes, values exceeding the threshold for the diagnosis of acute myocardial infarction were detected. Despite such high
troponin values, they did not complain on chest pain neither had ECG changes suggestive of an acute myocardial infarction. In athletes with high troponin values, contrast-enhanced magnetic resonance imaging of the heart found no signs of myocardial necrosis. Also, the kinetics of troponin increase did not correspond to that in acute myocardial infarction. So, it is supposed
that such increase in troponin is due to the increased mechanical load on the myocardium. There is no association between transient cardiac dysfunction after intense physical activity and an increase in cardiac biomarkers. Accelerated coronary artery atherosclerosis, a higher risk of atrial fibrillation and myocardial fibrosis have been observed in middle-aged and elderly people
who have been or are engaged in intense physical activity. Despite these findings, there is no clear evidence that intense physical activity is harmful to health.
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BACKGROUND A normal coronary angiogram in ST-elevation myocardial infarction (STEMI) can be considered a myocardial infarction with non-obstructive coronary arteries (MINOCA) until an alternative diagnosis is obtained. However, the COVID-19 pandemic might delay urgent coronary angiography in a resource-limited setting. Perimyocarditis often causes symptoms, such as chest pain, as well as ST-elevation and high cardiac troponin levels. This STEMI mimicker can also cause cardiogenic shock and death when not treated properly. CASE REPORT A 40-year-old man reported having acute onset of substernal chest pain, which was suspected to be STEMI. The patient was an active smoker without any risk factors or a history of cardiovascular disease. The examination showed elevated cardiac troponin I, ST-elevation in high lateral leads, and regional wall motion abnormality (RWMA) by echocardiogram. Furthermore, thrombolytic therapy had failed, and rescue percutaneous coronary intervention was not performed due to the catheterization laboratory limitation during the COVID-19 pandemic. Before coronary angiography, the patient was scheduled for 2 consecutive days of COVID-19 polymerase chain reaction (PCR) swabs. On the second day of hospitalization, the patient experienced a cardiogenic shock. The COVID-19 PCR results were negative, while coronary angiography revealed normal coronary arteries. The patient was eventually diagnosed with probable acute perimyocarditis. CONCLUSIONS Myocarditis is implicated in young patients without typical cardiovascular risk factors or in those with recent infection and cardiovascular symptoms mimicking acute coronary syndrome. It might also be present in situations where ST-elevation distribution on the electrocardiogram is discordant with the RWMA observed on the echocardiogram.
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Unstable angina
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TIMI
Stress Echocardiography
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A 72-year-old lady without any conventional cardiovascular risk factors presented to the emergency room with severe anginal chest pain. ECG showed lateral wall ST-elevation and serial serum troponins were elevated. Emergent cardiac catheterization showed spontaneous coronary artery dissection involving the first diagonal artery with angiographically normal other epicardial coronary arteries. Left ventriculogram and echocardiogram showed a moderately reduced left ventricular systolic function with akinetic mid to distal myocardial segments and normal basal contraction suggestive of stress-induced cardiomyopathy. Spontaneous coronary artery dissection presenting with ST-elevation myocardial infarction and stress-induced cardiomyopathy is very rare.
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Objective:To explore the clinical characteristics,diagnosis and prognosis of chronic obstructive pulmonary disease(COPD) complicated by acute myocardial infarction(AMI).Methods:A total of 201 AMI patients were divided according to their history of COPD into Group A(with COPD,n= 43) and B(without COPD,n=158).Comparative analyses were made of such clinical data as symptoms,kinds of arrhythmia,the rates of ST-and non ST-segment elevation myocardial infarction(STEMI and NSTEMI),peak levels of creatine kinase-MB(CK-MB) and cardiac troponin-T(cTn-T).All the patients were followed up for 6 months.The rates of re-myocardial infarction and re-admission and mortality were compared.Results:The incidence of chest pain was significantly lower,while that of pulmonary edema and cardiogenic shock statistically higher in Group A than in B(25.6% vs 60.1%,P0.01; 48.8% vs 20.2%,P0.01;20.9% vs 8.8%,P0.05).The rate of NSTEMI was slightly higher in the former than in the latter(30.2% vs 17.1%,P0.05).No statistical differences were observed either in the peak levels of CK-MB and cTn-T or in the incidence of re-myocardial infarction between the two groups.The percentage of re-admission and mortality were significantly higher in Group A(23.2% and 16.2%) than in B(10.1% and 6.3%)(P0.05). Conclusion:COPD patients with AMI have a low incidence of chest pain,high incidences of pulmonary edema and cardiogenic shock,a high rate of readmission,poor prognosis and high mortality.ECG tracing and myocardial zymogram may help to make a definite diagnosis.
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Objective: Creatine kinase-myocardial band (CK-MB) and troponin-I are the most specific and accurate indicators of myocardial infarction among different cardiac biomarkers. However, few studies have examined the correlation between temporal changes of these biomarkers and high risk echocardiographic and angiographic variables. The aim of our study was to assess the relationship between these variables. Methods: Our study was a prospective study of 113 patients with a diagnosis of non-ST-elevation myocardial infarction (NSTEMI) who were admitted within the first hours of the onset of chest pain. Troponin-I and CK-MB were measured serially at the time of hospital admission, at 6-9 hours and again at 12-24 hours. All patients underwent transthoracic echocardiography and coronary angiography and left ventricular ejection fraction (LVEF), mitral regurgitation and severity of coronary artery disease were determined. Results: Troponin-I level within 6-9 hours after admission was significantly associated with significant coronary artery disease among different variables (P-value=0.032, odds ratio=1.11, 95% confidence interval [1.01- 1.22]). Also, patients younger than 65 years of age had higher levels of troponin-I within 6-9 and 12-24 hours after admission (P value 0.07 and 0.027, respectively). On the other hand, patients with LVEF < 35% and hypertensive patients had higher levels of CK-MB within 6-9 and 12-24 hours, respectively (P value 0.042 and 0.023). Conclusion: Temporal changes of troponin-I and CK-MB after NSTEMI can be an important indicator for risk stratifying of these patients.
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Takotsubo cardiomyopathy is characterized by transient left ventricular apical ballooning, which results in temporary left ventricular dysfunction. We present a case of a 62-year-old female who presented with chest pain and shortness of breath. Her electrocardiogram was suggestive of myocardial ischemia and her troponin levels were elevated. Cardiac catheterization showed mild coronary artery disease and left ventriculography revealed severe apical hypokinesia. A diagnosis of Takotsubo cardiomyopathy was made. Her hospital stay was complicated by cardiogenic shock. One of the risk factors was cannabis use. Hence, our case highlights the management of Takotsubo cardiomyopathy and its complications, along with focus on cannabis use and its association with Takotsubo cardiomyopathy.
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Abstract A patient with cardiogenic shock had typical electrocardiographic findings of acute anterior transmural myocardial infarction. Cardiac catheterization revealed normal coronary arteries and severe biventricular failure. Postmorten examination confirmed normal coronary arteries; acute myocarditis, but no evidence for infarction, was found. Electrocardiographic changes of myocarditis may be indistinguishable from acute transmural infarction. In suspected cases, cardiac catheterization should be considered prior to thrombolytic therapy.
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Acute myocarditis
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