Acute anterior myocardial infarction after being struck on the chest by a soccer ball

Transcription

1 Hong Kong Journal of Emergency Medicine Acute anterior myocardial infarction after being struck on the chest by a soccer ball 胸部被足球撞擊而引致急性前壁心肌梗塞 RE Altekin, A Er, C Oktay, AO Baktir, A Yanikoglu, AS Yalcinkaya, ME Kavasoglu Blunt chest wall trauma is one of the non-atherosclerotic causes of myocardial infarction. Motor vehicle accident is the most common cause of myocardial infarction followed by sports injuries. Myocardial infarction can occur due to traumatic coronary artery laceration with thrombus formation or dissection. Lethal complications may result if accompanying myocardial infarction is overlooked in patients whose chest pain is considered to be solely related to the localised blunt chest wall trauma by the physician and the patient. Here we present a case of acute anterior myocardial infarction secondary to a blunt chest trauma after being struck on the chest by a soccer ball during a recreational soccer game and review the current literature on the diagnosis and treatment of traumatic myocardial infarction. (Hong Kong j.emerg.med. 2011;18: ) 胸部鈍傷是一種非動脈粥樣硬化而導致心肌梗塞的原因 機動車輛交通事故是最常見的原因, 其次是運動傷害 外傷引致冠狀動脈血栓形成或撕裂可能會引受致心肌梗塞 醫生如以為病人的胸部疼痛僅涉及到局部胸壁鈍傷而忽略可引起心肌梗塞的致命併發症, 則後果堪虞 在這裡, 我們提出一個在足球比賽中繼發於胸部鈍傷之急性前壁心肌梗塞及檢討目前診斷和治療外傷性心肌梗塞的文獻 Keywords: Balloon angioplasty, blunt chest trauma, coronary thrombosis 關鍵詞 : 氣球血管擴張術 胸部鈍傷 冠狀動脈血栓塞 Correspondence to: Cem Oktay, MD Akdeniz University School of Medicine, Department of Emergency Medicine, Antalya, Turkey cemoktay@akdeniz.edu.tr Mehmet Emin Kavasoglu, MD Akdeniz University School of Medicine, Department of Cardiology, Antalya, Turkey Refik Emre Altekin, MD Arzu Er, MD Atakan Yanikoglu, MD Ali Selim Yalcinkaya, MD Private Life Hospital, Department of Cardiology, Antalya, Turkey Ahmet Oguz Baktir, MD Introduction The exact incidence of blunt cardiac injur y is unknown; however the risk varies from 8% to 71% of all blunt chest injured patients. 1 Cardiac arrhythmias, myocardial muscle contusion, valvular disruption, coronary artery injury, even cardiac chamber rupture and pericardial tamponade may result with blunt chest wall trauma. 2 Blunt chest trauma is one of the causes of non-atherosclerotic myocardial infarction. Intimal laceration and thrombotic process activation are the responsible pathophysiological mechanisms for the relevant clinical presentation. 3 Motor vehicle accident (64%) is the most common cause of such myocardial

2 Altekin et al./blunt chest traum 121 infarctions followed by sports injuries (17%). 4 Here we present the management of a case of a young patient with acute myocardial infarction after being struck on the chest by a soccer ball. Case report A 22-year-old male university student presented to the emergency department (ED) with a squeezing type of chest pain after having been struck on the anterior chest wall by a soccer ball kicked from about one meter. He continued to play for about 20 minutes till the end of the game in spite of his mild chest pain. He presented to the ED 4 hours afterwards because he felt severe persistent pain even at rest. He was immediately triaged to the monitored area in the ED. The patient had no notable medical or surgical history and he had no other cardiac risk factors apart from smoking a packet of cigarettes daily for 5 years. On initial examination, his blood pressure was 110/ 80 mmhg, pulse rate was 74 beats/min and respiratory rate was 22 breaths/min. On cardiac auscultation, there was a grade 1/6 systolic murmur. Respiratory and other systems examination were normal. The findings of an immediately performed 12-lead electrocardiogram (ECG) were consistent with acute anterior wall myocardial infarction (Figure 1). Segmental wall motion abnormality was detected by two-dimensional echocardiography in the ED. Serum cardiac enzymes obtained in the ED were also elevated: Troponin-T level was 0.41 g/l (normal ), CK-MB mass was g/l (normal ), and myoglobin was >171.3 nmol/l (normal ). Patient was immediately transferred to coronary angiography laboratory in 20 minutes and emergency coronary angiography was performed. Left anterior descending (LAD) ostial occlusion was seen on angiography (Figure 2-A). Balloon angioplasty was performed with mm sized balloon at the LAD ostial occlusion and dissection tract lying from ostium to proximal of LAD was detected (Figure 2-B). Ephesos mm sized stent (bare metal stent) was implanted to the lesion (Figure 2-C). In control angiographic views, filling defects were observed because of scattered thrombus particles at distal part of left main coronary artery, LAD ostium and circumflex artery (Figure 2- D). Intervention was ended and tirofiban infusion was planned because of thrombus load and TIMI 2 flow at the distal segment of LAD (Figure 2-D). Patient was admitted to the coronary care unit (CCU) and appropriate medications were continued. Other specific laboratory test results obtained in the CCU were as follows: serum glucose 6.16 mmol/l (normal ), creatinine 87.5 mol/l (normal ), Figure 1. Initial 12-lead electrocardiogram performed in the emergency department. ST-elevation in Lead I, avl and V 2 through V 6 was concordant with acute anterior wall myocardial infarction.

3 122 Hong Kong j. emerg. med. Vol. 18(2) Mar 2011 triglyceride mmol/l (normal ), LDL cholesterol 1.85 mmol/l (normal ), HDL cholesterol mmol/ L ( normal ), lipoprotein (a) 5 mol/l (normal ), and homocysteine 6.35 mol/l (n ormal 5-15). Echocardiography on the 4th day after intervention showed that the left ventricular end-diastolic and endsystolic diameters were 53 mm and 40 mm respectively, ejection fraction was 35%, there were segmental wall motion abnormality in the infarct zone, grade 2 spontaneous echo contrast in left ventricle and grade 1 mitral regurgitation. Patient was stable during his admission and discharged home on the fifth day after intervention. Figure 2. Coronary angiogram images: (A) LAD ostial occlusion, (B) LAD dissection after angioplasty, (C) Stenting of LAD dissection, and (D) Angiographic LAD view after stenting.

4 Altekin et al./blunt chest traum 123 Discussion Intimal tear and plaque rupture associated thrombosis underlie the pathophysiology of trauma-related myocardial infarction. Coronary artery dissection, spasm, rupture, and compression due to epicardial haematoma can be the other causes. 3 In a study which examined trauma related myocardial infarction, the most commonly involved arteries were LAD (71.4%) and RCA (19%) respectively. 4 LAD is more susceptible to injury after blunt chest trauma because of its anterior location. Acceleration and deceleration forces are thought to be an explanation for injury of RCA after blunt trauma. Also in the same study, only 9% of myocardial infarction cases after chest trauma could be detected in first 24 hours and 13% of patients in first week. 4 In order to diagnose a possible myocardial infarction after chest trauma, ECG should be performed. Serum cardiac enzymes should also be studied to diagnose any myocardial damage. Bedside echocardiography can be useful in equivocal cases for the differential diagnosis of coronary occlusion, contusion or other myocardial damage. 5 As computed tomography scan of the chest has become a test of choice for evaluation of major chest trauma, contrast-enhanced images should be evaluated carefully to determine any myocardial perfusion defect suggesting an underlying coronary injury. 6 Treatment approach to myocardial infarction after blunt chest trauma has been controversial and differs according to the concomitant injuries and organ damage and the existence of bleeding. Current literature reveals that there were cases managed conservatively. 7,8 In a similar group of patients, thrombolytic treatment were found to be effective, however risk of bleeding limits its routine use. 9 Another approach for those patients is immediate coronary angiography and revascularisation with percutaneous coronary intervention if possible. 10 However in some cases there was no coronary lesion found; coronary spasm and resolved thrombus were believed to be the responsible mechanisms for such clinical presentation. 4 In such a case that coronary arteries are normal angiographically, magnetic resonance imaging can be a useful tool to visualise the underlying pathology; delayed gadolinium enhancement can reveal myocardial contusion and subendocardial/transmural myocardial infarction. 11 Also, coronary dissection with good coronary flow was detected in some patients, and it was seen that most of them heal in a 6 months period spontaneously without any intervention. 12 Conclusion A high index of suspicion is important to diagnose myocardial infarction associated with blunt chest trauma. Both the health care providers and the patients should consider a serious pathology of cardiac origin when there is persistent chest pain even after moderate degree of trauma like being struck by a soccer ball during a nonprofessional game. Besides the systemic evaluation of the patient, obtaining ECG and serum cardiac enzyme are essential, and cardiac imaging should also be done in equivocal cases. After prompt diagnosis, invasive inter vention should be the treatment of choice, if available; otherwise fibrinolytic therapy or conservative treatment strategy can be considered on a case to case basis. Acknowledgements This study was supported by the Akdeniz University Scientific Research Project Unit. References 1. McGillicuddy D, Rosen P. Diagnostic dilemmas and current controversies in blunt chest trauma. Emerg Med Clin N Am 2007;25(3): Atalar E, Açil T, Aytemir K, Ozer N, Ovünç K, Aksöyek S, et al. Acute anterior myocardial infarction following a mild nonpenetrating chest trauma - a case report. Angiology 2001;52(4): Imamura M, Tsuchiya Y, Tahara H, Nii T, Nakashima Y, Arakawa K, et al. Acute myocardial infarction in a patient with primary coronary dissection and severe coronary vasospasm. A case report. Angiology 1995;46 (10): Christensen MD, Nielsen PE, Sleight P. Prior blunt

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