Coronary artery dissection and acute myocardial infarction following blunt chest trauma
© Bjørnstad et al; licensee BioMed Central Ltd. 2009
Received: 15 December 2008
Accepted: 14 April 2009
Published: 14 April 2009
Blunt chest trauma might lead to cardiac injury ranging from simple arrhythmias to lethal conditions such as cardiac rupture. We experienced a case of initially overlooked traumatic coronary artery dissection which resulted in acute myocardial infarction (AMI). A high degree of suspicion is needed to diagnose this condition. Based on our case, we will give an overview of relevant literature on this topic. ECG, echocardiography, coronary angiography and cardiac enzymes are valuable tools in diagnosing this rare condition. The time span from coronary artery occlusion to revascularisation must be short if AMI is to be avoided.
Blunt chest trauma might lead to cardiac injury ranging from simple arrhythmias to lethal conditions such as cardiac rupture. Acute myocardial infarction (AMI) may be induced by blunt chest trauma [1–3]. We experienced a case of coronary artery dissection with subsequent myocardial infarction from blunt chest trauma. We will give an overview of relevant literature regarding this topic.
Coronary artery injury may cause AMI, but the natural history of intimal rupture or dissection is not known. Spontaneous healing of the vessel has been described with some degree of residual stenosis  and without sequelae . Development of persistent angina pectoris following blunt trauma has been attributed to coronary artery injury in three cases [3, 11, 24]. Development of coronary artery aneurysm has also been reported .
AMI from blunt chest trauma has been managed in several ways. Conservative treatment with inotropic support, if necessary, has resulted in post-infarction sequelae with reduced ejection fraction and cardiac symptoms . Fibrinolytic therapy has been given after mild trauma . Acute percutaneous intervention (PCI) both without  and with stent implantation has been performed with successful revascularization and reversal of ST-elevations  although restenosis has been described . In our patient PCI was performed and a stent was implanted. As the condition was perceived as cardiac contusion and coronary artery injury was not suspected initially, cardiac catheterization and PCI was performed on the fourth day, after the AMI had taken place. Recovery was uneventful, however, and our patient was fully rehabilitated. Coronary artery bypass grafting has been performed acutely  and delayed in combination with coronary aneurysm repair  or resection of left ventricular aneurysm and coronary embolectomy . In the multi-traumatized patient off-pump coronary artery bypass (OPCAB) is probably favourable over on-pump surgery . OPCAB is performed without the use of cardiopulmonary bypass resulting in a less coagulopathic procedure. For patients with head injury cardiopulmonary bypass may be a particular risk as cerebral perfusion might be reduced. Avoiding cardiopulmonary bypass might also reduce the risk of organ failure. Moreover, avoiding cardioplegic arrest might be favourable in the case of cardiac contusion since myocardial ischemia also may contribute negatively.
The possibility of coronary artery injury should be kept in mind after blunt thoracic trauma. This condition probably is underdiagnosed being misinterpreted as cardiac contusion. Modern principles of coronary artery revascularization make myocardial salvage possible, also in the traumatized patient. Following a case of initially overlooked traumatic coronary artery dissection which resulted in AMI we have changed our diagnostic algorithm after blunt chest trauma. ECG is recorded from every patient together with cardiac enzymes. An abnormal ECG and/or abnormal cardiac enzymes warrant further investigation. Both echocardiography and coronary angiography are used when appropriate. The time span from coronary artery occlusion to revascularisation must be short if AMI is to be avoided.
The patient has given consent for the case report to be published.
The case report was presented at the 82nd annual meeting of The Norwegian Surgical Association in 2006. The conference proceedings have not been published in a peer reviewed journal.
- Pifarre R, Grieco J, Garibaldi A, Sullivan HJ, Montoya A, Bakhos M: Acute coronary artery occlusion secondary to blunt chest trauma. J Thorac Cardiovasc Surg. 1982, 83: 122-125.PubMedGoogle Scholar
- Salmi A, Blank M, Slomski C: Left anterior descending artery occlusion after blunt chest trauma. J Trauma. 1996, 40: 832-834. 10.1097/00005373-199605000-00028.View ArticlePubMedGoogle Scholar
- Christensen MD, Nielsen PE, Sleight P: Prior blunt chest trauma may be a cause of single vessel coronary disease; hypothesis and review. Int J Cardiol. 2006, 108: 1-5. 10.1016/j.ijcard.2005.04.010.View ArticlePubMedGoogle Scholar
- Parmley LF, Manion WC, Mattingly TW: Nonpenetrating traumatic injury of the heart. Circulation. 1958, 18: 371-396.View ArticlePubMedGoogle Scholar
- Wang LT, Cheng SM, Chang LW, Liu MY, Wu CP, Hseih DS: Acute myocardial infarction caused by occult coronary intimal dissection after a heel stomp: a case report. J Trauma. 2008, 64: 824-826.PubMedGoogle Scholar
- Aoyagi S, Okazaki T, Fukunaga S, Ueda T: Concomitant traumatic aortic valve and coronary artery injury. Ann Thorac Surg. 2007, 83: 289-291. 10.1016/j.athoracsur.2006.06.021.View ArticlePubMedGoogle Scholar
- Li CH, Chiu TF, Chen JC: Extensive anterolateral myocardial infarction caused by left main coronary artery dissection after blunt chest trauma: a case report. Am J Emerg Med. 2007, 25: 858-5. 10.1016/j.ajem.2007.01.020.View ArticlePubMedGoogle Scholar
- Nan YY, Chang JP, Lu MS, Kao CL: Mediastinal hematoma and left main dissection following blunt chest trauma. Eur J Cardiothorac Surg. 2007, 31: 320-321. 10.1016/j.ejcts.2006.11.019.View ArticlePubMedGoogle Scholar
- Pawlik MT, Kuenzig HO, Holmer S, Lemberger P, Pfister K, Schreyer AG, Kasprzak P: Concurrent carotid rupture and coronary dissection after blunt chest trauma. J Trauma. 2007, 63: E69-E72. 10.1097/01.ta.0000246185.62754.d5.View ArticlePubMedGoogle Scholar
- Ryu JK, Kim KS, Lee JB, Choi JY, Chang SG, Ko S: Coronary artery stenting in a patient with angina pectoris caused by coronary artery dissection after blunt chest trauma. Int J Cardiol. 2007, 114: e89-e90. 10.1016/j.ijcard.2006.06.036.View ArticlePubMedGoogle Scholar
- Sato Y, Matsumoto N, Komatsu S, Matsuo S, Kunimasa T, Yoda S, Ichikawa M, Kasamaki Y, Takahashi M, Uchiyama T: Coronary artery dissection after blunt chest trauma: depiction at multidetector-row computed tomography. Int J Cardiol. 2007, 118: 108-110. 10.1016/j.ijcard.2006.05.075.View ArticlePubMedGoogle Scholar
- Smayra T, Noun R, Tohme-Noun C: Left anterior descending coronary artery dissection after blunt chest trauma: assessment by multi-detector row computed tomography. J Thorac Cardiovasc Surg. 2007, 133: 811-812. 10.1016/j.jtcvs.2006.11.026.View ArticlePubMedGoogle Scholar
- Campbell CY, Record JD, Kolandaivelu A, Ziegelstein RC: Chest pain in a young basketball player. J Gen Intern Med. 2006, 21: C7-10. 10.1111/j.1525-1497.2006.00400.x.PubMed CentralView ArticlePubMedGoogle Scholar
- Korach A, Hunter CT, Lazar HL, Shemin RJ, Shapira OM: OPCAB for acute LAD dissection due to blunt chest trauma. Ann Thorac Surg. 2006, 82: 312-314. 10.1016/j.athoracsur.2005.09.070.View ArticlePubMedGoogle Scholar
- Leong D, Brown M: Blunt traumatic dissection of the proximal left anterior descending artery. Emergency Medicine Journal. 2006, 23: e67-10.1136/emj.2006.041426.PubMed CentralView ArticlePubMedGoogle Scholar
- Ginzburg E, Dygert J, Parra-Davila E, Lynn M, Almeida J, Mayor M: Coronary artery stenting for occlusive dissection after blunt chest trauma. J Trauma. 1998, 45: 157-161. 10.1097/00005373-199807000-00034.View ArticlePubMedGoogle Scholar
- Vasudevan AR, Kabinoff GS, Keltz TN, Gitler B: Blunt chest trauma producing acute myocardial infarction in a rugby player. Lancet. 2003, 362: 370-10.1016/S0140-6736(03)14024-X.View ArticlePubMedGoogle Scholar
- Greenberg J, Salinger M, Weschler F, Edelman B, Williams R: Circumflex coronary artery dissection following waterskiing. Chest. 1998, 113: 1138-1140. 10.1378/chest.113.4.1138.View ArticlePubMedGoogle Scholar
- Grady AE, Cowley MJ, Vetrovec GW: Traumatic dissecting coronary arterial aneurysm with subsequent complete healing. Am J Cardiol. 1985, 55: 1424-1425. 10.1016/0002-9149(85)90518-1.View ArticlePubMedGoogle Scholar
- Tønnessen T, Pillgram-Larsen J, Hausken J, Vengen ØA: Acute chordae rupture of the mitral valve following moderate blunt chest trauma: Successful mitral valve repair. European Journal of Trauma. 2005, 31: 72-73. 10.1007/s00068-005-1434-0.View ArticleGoogle Scholar
- Thorban S, Ungeheuer A, Blasini R, Siewert JR: Emergent interventional transcatheter revascularization in acute right coronary artery dissection after blunt chest trauma. J Trauma. 1997, 43: 365-367. 10.1097/00005373-199708000-00029.View ArticlePubMedGoogle Scholar
- Westaby S, Drossos G, Giannopoulos N: Posttraumatic coronary artery aneurysm. Ann Thorac Surg. 1995, 60: 712-713. 10.1016/0003-4975(95)00342-I.View ArticlePubMedGoogle Scholar
- Masuda T, Akiyama H, Kurosawa T, Ohwada T: Long-term follow-up of coronary artery dissection due to blunt chest trauma with spontaneous healing in a young woman. Intensive Care Med. 1996, 22: 450-452. 10.1007/BF01712164.View ArticlePubMedGoogle Scholar
- Loss DM, MacMillan RM, Maranhao V: Coronary artery obstruction due to blunt chest trauma with residual angina pectoris. Cathet Cardiovasc Diagn. 1983, 9: 297-301. 10.1002/ccd.1810090309.View ArticlePubMedGoogle Scholar
- Kahn JK, Buda AJ: Long-term follow-up of coronary artery occlusion secondary to blunt chest trauma. Am Heart J. 1987, 113: 207-210. 10.1016/0002-8703(87)90035-4.View ArticlePubMedGoogle Scholar
- Marcum JL, Booth DC, Sapin PM: Acute myocardial infarction caused by blunt chest trauma: successful treatment by direct coronary angioplasty. Am Heart J. 1996, 132: 1275-1277. 10.1016/S0002-8703(96)90475-5.View ArticlePubMedGoogle Scholar
- Gustavsson CG, Albrechtsson U, Forslind K, Stahl E, White T: A case of right coronary artery occlusion, caused by blunt chest trauma and treated with acute coronary artery bypass surgery. Eur Heart J. 1992, 13: 133-136.PubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.