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Myocardial Infarction Secondary to Blunt Chest Trauma

Published:January 03, 2017DOI:https://doi.org/10.1016/j.amjms.2016.12.010

      Abstract

      Myocardial infarction (MI) following blunt chest trauma is rare, but potentially fatal. We treated a young patient for acute MI after falling chest-first on ice while playing hockey. Coronary artery bypass grafting (CABG) was performed after percutaneous stenting attempts were unsuccessful. By reviewing the related literature, we found 179 cases, the majority of which affected young males following road accidents. Left anterior descending artery was most frequently affected followed by right coronary artery particularly in their proximal thirds. Prior to the advent of emergent angioplasty for MI, conservative management was frequently pursued, whereas subsequently both stenting and CABG were performed as initial therapy. Several cases required CABG after the failure of stenting attempts. Trauma-associated MI is uncommon but should be suspected to be properly diagnosed and managed; the potential need for CABG requires that a cardiac surgeon be informed at the time of angiography to avoid possible delay in revascularization.

      Key Indexing Terms

      Introduction

      Cardiovascular disease remains the leading cause of death in the United States

      Murphy SL, Xu J, Kochanek KD. Deaths: Preliminary Data for 2010. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 2012;60(4):1–52.

      ; it poses a significant burden on the economy
      • Lloyd-Jones D.
      • Adams R.J.
      • Brown T.M.
      • et al.
      Heart disease and stroke statistics—2010 update. A report from the American Heart Association.
      and compromises the lifestyle of the patients.
      • Schweikert B.
      • Hunger M.
      • Meisinger C.
      • et al.
      Quality of life several years after myocardial infarction: comparing the MONICA/KORA registry to the general population.
      Myocardial infarction (MI) is an essential subset of these ailments. It comprises a medical emergency where every minute counts,
      • De Luca G.
      • Suryapranata H.
      • Ottervanger J.P.
      • et al.
      Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction every minute of delay counts.
      • Cannon C.P.
      • Gibson C.M.
      • Lambrew C.T.
      • et al.
      Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction.
      and every effort should be made to minimize the time needed to reperfuse the myocardium and increase the chances of a better outcome.
      • Cannon C.P.
      • Gibson C.M.
      • Lambrew C.T.
      • et al.
      Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction.
      Despite the great advances in diagnosing and managing MI, a significant proportion may pass unrecognized,
      • de Torbal A.
      • Boersma E.
      • Kors J.A.
      • et al.
      Incidence of recognized and unrecognized myocardial infarction in men and women aged 55 and older: the Rotterdam Study.
      especially in its atypical presentations.
      • Canto J.G.
      • Shlipak M.G.
      • Rogers W.J.
      • et al.
      Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain.
      • Pope J.H.
      • Aufderheide T.P.
      • Ruthazer R.
      • et al.
      Missed diagnoses of acute cardiac ischemia in the emergency department.
      This poses a grave medical dilemma and can result in suboptimal outcomes.
      • Kannel W.B.
      • Abbott R.D.
      Incidence and prognosis of unrecognized myocardial infarction: an update on the Framingham study.
      Cardiovascular injuries following blunt chest trauma (BCT) were first described by Akenside
      • Akenside M.
      An account of a blow upon the heart, and of its effects: by Mark Akenside, MDFRS and physician to her majesty.
      in 1764. They are common and vary broadly in type and severity, with imaging and electrocardiographic (EKG) abnormalities being detected in more than half of BCT cases.
      • Salim A.
      • Velmahos G.C.
      • Jindal A.
      • et al.
      Clinically significant blunt cardiac trauma: role of serum troponin levels combined with electrocardiographic findings.
      • Sutherland G.R.
      • Driedger A.A.
      • Holliday R.L.
      • et al.
      Frequency of myocardial injury after blunt chest trauma as evaluated by radionuclide angiography.
      Acute MI following BCT, however, is uncommon, but its burden is significant as it affects young, previously healthy individuals.
      • Ismailov R.M.
      • Ness R.B.
      • Weiss H.B.
      • et al.
      Trauma associated with acute myocardial infarction in a multi-state hospitalized population.
      Previous reports have shown that this entity was found in 2% of autopsies of BCT victims, and that only 13% of the cases underwent coronary catheterization in the first 24 hours.
      • Lai C.H.
      • Ma T.
      • Chang T.C.
      • Chang M.H.
      • et al.
      A case of blunt chest trauma induced acute myocardial infarction involving two vessels.
      The diagnosis may be delayed because of complicated polytrauma where chest pain may not be considered cardiac in origin.
      • Furukawa S.
      • Wingenfeld L.
      • Takaya A.
      • et al.
      An autopsy case of blunt chest trauma from a traffic accident complicated by chest compression due to resuscitation attempts.
      The available data regarding MI in BCT are largely based on case reports. In 2005, Christensen et al
      • Christensen M.D.
      • Nielsen P.E.
      • Sleight P.
      Prior blunt chest trauma may be a cause of single vessel coronary disease; hypothesis and review.
      reviewed 77 published cases revealing that the left anterior descending artery (LAD) is the most commonly affected vessel in these injuries, and that automobile accident is the most common causative trauma. Detailed information regarding coronary injuries and the best approach to treatment is lacking.
      We recently observed a case of total occlusion of the right coronary artery (RCA) in a young man after BCT, which required coronary artery bypass grafting (CABG) after percutaneous attempts to wire the thrombus did not succeed. We report this case, review the related literature and discuss the findings for possible therapeutic implications.

      Case Presentation

      A 44-year-old man presented with sharp substernal pain that started after falling chest first on the ice while playing hockey. The pain did not radiate and reached 8/10 in intensity. The patient thought that his pain was due to the fall itself. He stopped playing hoping that the pain would subside; however, it only worsened.
      The patient had a history of hypertension controlled with lisinopril 40 mg daily and dyslipidemia medicated with fenofibrate 200 mg daily. His family history was significant for premature coronary artery disease as his brother and grandfather died of MI at the age of 42 and 50 years, respectively. He did not smoke and led an active lifestyle.
      When the pain became unbearable, the patient drove to an urgent care facility where a 12-lead EKG showed ST-segment elevation in leads II, III and augmented vector foot with reciprocal changes. The patient was transferred to our hospital where his initial blood pressure was 146/66 mm Hg, heart rate was 85 beat per minute and oxygen saturation was 96% on 3 L of oxygen per nasal cannula. A repeat EKG in the hospital showed sinus rhythm with a prominent R wave in V2, and ST-segment elevation in lead III greater than lead II, suggesting an inferior MI with posterior and right ventricular involvement (Figure 1). Emergent coronary angiogram showed a hyperdominant right circulation with an obstructing clot in the mid segment of the RCA where the thrombus burden was deemed to be high (Figure 2). As the right circulation was perfusing a large proportion of the myocardium and as prior thrombectomy trials had failed, the patient underwent emergent coronary artery bypass surgery with left saphenous vein grafting to the posterior descending artery without complication. During the procedure, multiple clots were flushed out of the artery, and an intimal dissection was seen. In the coronary care unit, the 2D echocardiogram showed global hypokinesia with ejection fraction of 40% and severe right ventricular dysfunction with anterolateral akinesia. The patient had multiple episodes of paroxysmal atrial fibrillation that were treated with sotalol in addition to warfarin. The patient was stabilized and discharged on postoperative day 11.
      FIGURE 1
      FIGURE 1Initial electrocardiogram with findings suggestive of inferior and right myocardial infarction.
      FIGURE 2
      FIGURE 2Angiography showing (A) acute mid right coronary artery occlusion (arrow) and (B) patent left circulation.

      Review of Literature

      We conducted a web-based search of the literature for case reports of MI induced by BCT using PubMed and Google Scholar with keywords: MI, trauma, and BCT. We also reviewed the references cited in the retrieved articles to obtain all possible cases. For a case to be included, it had to fulfill the World Health Organization definition of MI based on symptoms, EKG findings and elevation of cardiac enzymes,
      • Thygesen K.
      • Alpert J.S.
      • Jaffe A.S.
      • et al.
      Third universal definition of myocardial infarction.
      with a logical chronological course of events where the infarction evolved as a direct result of the trauma. The primary search resulted in 746 articles of which 157 PubMed-indexed articles and abstracts were included, describing 179 different cases; these were analyzed after adding our patient׳s case. The data were double-checked for accuracy before analysis; the results are presented as percentage of the available data.

      Results

      Most cases (89%) occurred in males (Table 1). The mean age of the patients was 35 years, with 74% being between 20 and 50 years old.
      TABLE 1Clinical features.
      n (%)
      Sex
       Male158 (89%)
       Female21 (11%)
       N/A2
      Age: mean ± SD = 35 ± 13
       <2020 (11%)
       20-3046 (26%)
       30-4052 (29%)
       40-5034 (19%)
       >5027 (15%)
       N/A1
      Trauma
       Car accident76 (43%)
       Sport39 (22%)
       Motorcycle21 (12%)
       Physical altercation15 (9%)
       Occupational injuries12 (7%)
       Other13 (7%)
       NA4
      Presenting symptoms
       Chest pain126 (83%)
       Obtunded/intubated16 (11%)
       Dyspnea6 (4%)
       Asymptomatic3 (2%)
       Sudden death1 (1%)
       N/A28
      Associated findings
       Rib/sternal fracture23 (13%)
      Angiographic findings
       Left main9 (5%)
       Two vessels10 (6%)
       Left anterior descending99 (58%)
        Proximal79 (85%)
        Middle13 (14%)
        Distal1 (1%)
        N/A6
       Left circumflex6 (4%)
       Right coronary artery24 (14%)
        Proximal15 (71%)
        Middle4 (19%)
        Distal2 (10%)
        N/A3
       Normal angiography21 (12%)
       CABG grafts2 (1%)
       N/A9
      Mechanism
       Dissection ± thrombosis120 (71%)
       Thrombosis/subtotal occlusion12 (7%)
       Coronary laceration6 (3%)
       Coronary aneurysm5 (3%)
       Compressive hematoma4 (2%)
       Normal angiography21 (12%)
       N/A12
      CABG, coronary artery bypass grafting, N/A: not available; SD, standard deviation.
      The trauma accounting for the injury was found to be road accidents in 55% and sport-related trauma in 22%.
      Chest pain was present in 83% of the patients. Further, 11% of the patients were obtunded or intubated where the diagnosis was made with EKG, cardiac enzymes elevation or inadvertently during imaging for other purposes. Echocardiography was abnormal in 96% of the cases with a variety of findings including, but not limited to, regional wall motion abnormalities, compromised systolic function and ventricular septal defect.
      Angiography revealed that the most frequently involved vessels were the LAD in 58% of cases and the RCA in 14%. The proximal segments of these vessels were most commonly affected. Normal angiography was found in 12% of the cases. Coronary dissection, with or without thrombosis, was the mechanism of injury in 120 cases (71%).
      Before proving the clear benefit of percutaneous angioplasty (PCI) in managing ST-elevation MI (PAMI Trial) in 1995,
      • Stone G.W.
      • Grines C.L.
      • Browne K.F.
      • et al.
      Predictors of in-hospital and 6-month outcome after acute myocardial infarction in the reperfusion era: the Primary Angioplasty in Myocardial Infarction (PAMI) trial.
      observation and medical therapy were the therapeutic options for chest trauma-induced MI (Table 2).
      TABLE 2Treatment and outcome.
      Pre-PAMI (1995)Post-PAMI (1995)
      Treatment
       Medical90 (57%)52 (84%)38 (39%)
       PTCA38 (24%)1 (2%)37 (38%)
       CABG/after failure of PTCA24 (15%)/7 (4%)6 (10%)/2 (3%)18 (19%)/5 (5%)
       Thrombolysis3 (2%)2 (3%)1 (1%)
       IC thrombolysis2 (1%)1 (1%)1 (1%)
       Aspiration101 (1%)
       Sudden death101 (1%)
       N/A211110
      Death14 (8%)4 (5%)10 (9%)
      Outcome of survived patients (n = 166)
       Heart failure24 (36%)8 (30%)16 (40%)
       Preserved function43 (64%)19 (70%)24 (60%)
       Not reported994257
      CABG, coronary artery bypass grafting; IC, intracoronary; N/A: not available; PAMI, primary angioplasty in myocardial infarction trial; PTCA, percutaneous transluminal coronary angioplasty.
      In cases published before the landmark PAMI trial, 52 patients (84%) received conservative treatment while 6 patients (10%) underwent CABG, of which 2 were after failure of PCI. The trend changed significantly after 1995, where 38 patients (39%) received conservative treatment and 37 patients (38%) had primary PCI. CABG was employed in 18 patients (19%), of which 6 underwent PCI. Overall, 14 patients died (8%), and we did not observe an improvement in this percentage between the 2 eras.
      Of the 166 patients who survived, 67 had follow-up information with 36% developing heart failure and 64% having preserved cardiac function.

      Discussion

      Our findings are largely in agreement with smaller previous reports.
      • Christensen M.D.
      • Nielsen P.E.
      • Sleight P.
      Prior blunt chest trauma may be a cause of single vessel coronary disease; hypothesis and review.
      The distribution of age, sex and causative trauma is similar to that of BCT in general, as it was found in a series of 515 patients that the mean age was 36.9 years and the male:female ratio was 2.7:1.
      • Shorr R.M.
      • Crittenden M.
      • Indeck M.
      • et al.
      Blunt thoracic trauma. Analysis of 515 patients.
      Suggested mechanisms of BCT-induced MI include direct impact, deceleration forces and sudden increase in systemic resistance known as water-hammer effect.
      • Foussas S.G.
      • Athanasopoulos G.D.
      • Cokkinos D.V.
      Myocardial infarction caused by blunt chest injury: possible mechanisms involved—case reports.
      • Fu M.O.
      • Wu C.J.
      • Hsieh M.J.
      Coronary dissection and myocardial infarction following blunt chest trauma.
      • Zerbo S.
      • Maresi E.
      • Portelli F.
      • et al.
      Death of a 23-year-old man from cardiac conduction system injury through a blunt chest impact after a car accident.
      The compliance of the sternum in younger patients may play a role in the insult by transmitting a higher proportion of the impact intrathoracically, which may also explain the preponderance of this condition to affect young individuals.
      • Zerbo S.
      • Maresi E.
      • Portelli F.
      • et al.
      Death of a 23-year-old man from cardiac conduction system injury through a blunt chest impact after a car accident.
      LAD was involved more frequently than RCA, although the latter is closer to the chest wall; this is explained by the vulnerable anatomic location of LAD for acceleration or deceleration forces during the traumatic event.
      • Bjørnstad J.L.
      • Pillgram-Larsen J.
      • Tønnessen T.
      Coronary artery dissection and acute myocardial infarction following blunt chest trauma.
      The proximal portions of the arteries are prone to dissection owing to their differential movement compared to the aortic root.
      • Fulda G.
      • Rodríguez A.
      • Turney S.
      • et al.
      Blunt traumatic rupture of the heart and pericardium: a ten-year experience (1979-1989).
      The relatively high percentage of normal angiographies may be due to the tendency of the coronary dissection to heal spontaneously in a similar fashion to the iatrogenic dissection related to cardiac interventions,
      • Park W.S.
      • Jeong M.H.
      • Hong Y.J.
      • et al.
      A case of acute myocardial infarction after blunt chest trauma in a young man.
      with another possibility being rapid recanalization of the thrombus.
      • Kotsovolis G.
      • Aidoni Z.
      • Geka E.
      • et al.
      Occlusion of the right coronary artery after blunt thoracic trauma with fatal outcome: a case report and review of the literature.
      Coronary dissection was the most common injury in these cases, which implies that thrombolytics may cause unfavorable outcomes necessitating pursuing different reperfusion modalities when possible.
      The death rate of 8% in our study may represent an underestimation, as it was previously reported at 15.5% of BCT in general.
      • Shorr R.M.
      • Crittenden M.
      • Indeck M.
      • et al.
      Blunt thoracic trauma. Analysis of 515 patients.
      This may be due to missing the diagnosis when death occurred early on or to the selective reporting of cases with successful outcomes.
      The diagnosis of MI following BCT is challenging owing to the distracting concomitant injuries and to the absence of a specific symptom or finding. Chest pain is often attributed to the concomitant injuries and may be absent in comatose patients. On the contrary, EKG changes including ST-segment elevation,
      • Kotsovolis G.
      • Aidoni Z.
      • Geka E.
      • et al.
      Occlusion of the right coronary artery after blunt thoracic trauma with fatal outcome: a case report and review of the literature.
      troponin elevation
      • Mori F.
      • Zuppiroli A.
      • Ognibene A.
      • et al.
      Cardiac contusion in blunt chest trauma: a combined study of transesophageal echocardiography and cardiac troponin I determination.
      and wall motion abnormalities
      • Sutherland G.R.
      • Driedger A.A.
      • Holliday R.L.
      • et al.
      Frequency of myocardial injury after blunt chest trauma as evaluated by radionuclide angiography.
      can be detected in more than half of BCT victims even without MI. Furthermore, coronary injury is not necessarily instantaneous and can develop days after the initial insult, as seen in human
      • Sato Y.
      • Matsumoto N.
      • Komatsu S.
      • et al.
      Coronary artery dissection after blunt chest trauma: depiction at multidetector-row computed tomography.
      and animal models.
      • Sabbah H.N.
      • Mohyi J.
      • Stein P.D.
      Coronary arteriography in dogs following blunt cardiac trauma: a longitudinal assessment.
      We think that it is reasonable to start evaluation of all patients with BCT by obtaining an EKG, then expanding the work-up if the EKG shows any concerning injury-like pattern or if the clinical suspicion is high.
      Different modalities have been used to visualize coronary dissection, sometimes accidently, including comprehensive echocardiography with Doppler studies,
      • Sun L.
      • Li Z.A.
      • Zhao Y.
      • et al.
      Left anterior descending artery occlusion secondary to blunt chest trauma diagnosed by comprehensive echocardiography and coronary angiography.
      • Meluzín J.
      • Groch L.
      • Toman J.
      • et al.
      Rupture of the coronary artery after blunt nonpenetrating chest wall trauma detected by color Doppler echocardiography: a case report.
      transesophageal echocardiography
      • Cherng W.J.
      • Bullard M.J.
      • Chang H.J.
      • et al.
      Diagnosis of coronary artery dissection following blunt chest trauma by transesophageal echocardiography.
      and multidetector computed tomography scan.
      • Malbranque G.
      • Serfaty J.M.
      • Himbert D.
      • et al.
      Myocardial infarction after blunt chest trauma: usefulness of cardiac ECG-gated CT and MRI for positive and aetiologic diagnosis.
      • Smayra T.
      • Noun R.
      • Tohmé-Noun C.
      Left anterior descending coronary artery dissection after blunt chest trauma: assessment by multi-detector row computed tomography.
      • Sato Y.
      • Matsumoto N.
      • Komatsu S.
      • et al.
      Coronary artery dissection after blunt chest trauma: depiction at multidetector-row computed tomography.
      Institutional preferences and expertise should be taken into account when pursuing the diagnosis. It is also essential to obtain a screening echocardiogram in patients who present with circulatory shock following BCT; segmental motion abnormalities should prompt further assessment and evaluation.
      • Sato Y.
      • Matsumoto N.
      • Komatsu S.
      • et al.
      Coronary artery dissection after blunt chest trauma: depiction at multidetector-row computed tomography.
      ,
      • Clancy K.
      • Velopulos C.
      • Bilaniuk J.W.
      • et al.
      Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline.
      Our findings support the sensitivity of echocardiogram, which was abnormal in most studied cases that reported these findings.
      In our results, we found that a few cases, including our patient, were switched to an emergent CABG when the thrombus was difficult to wire. The explanation to this observation is unclear; the dissection may trigger a large clot burden that may impair manipulation. We also found that approximately 11% of the cases involved either the left main or 2 arteries concomitantly, which may render interventional measures more difficult, and hence it is reasonable to activate the surgical team when facing BCT-induced MI to minimize the time to reperfusion in case of inability to perform successful PCI.
      Concomitant bleeding from other injuries is a major concern in treating patients with MI after BCT. Anticoagulation and antiplatelet therapy should only be initiated after significant and noncompressible bleeding has been ruled out. Frequent examinations and neurologic checks are also warranted after initiating these agents, and treatment should be considered if any symptoms related to potential bleeding develop.

      Conclusions

      MI in the context of BCT is a rare but devastating event. It mainly affects young patients and tends to occur in the proximal segments of both LAD and RCA with possible injuries to 2 arteries at a time in some cases. Timely diagnosis and treatment are crucial and STAT EKG should be obtained in all cases of chest trauma. Treatment should always be tailored depending on the concomitant injuries and the injury location. The urgent need for surgery remains a possibility should PCI prove inefficient or injuries seem not amenable to percutaneous measures.

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