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Coronary artery dissection and acute myocardial infarction following blunt chest trauma
World Journal of Emergency Surgery volume 4, Article number: 14 (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.
Parmley reported on 546 autopsy cases of blunt heart injury, and there were nine cases of coronary artery rupture and one case of intimal laceration . None of the cases, however, showed signs of coronary artery occlusion. AMI as a result of coronary artery dissection has been considered rare , however coronary artery dissection from blunt trauma has been more frequently described recently [5–15]. This might indicate that this condition previously has been underdiagnosed or is increasing in incidence. The left anterior descending coronary artery (LAD) is the vessel most often affected, and road traffic accidents are the usual cause of traumatic myocardial infarction [3, 16]. This susceptibility is attributable to the LAD's anatomic relation to the anterior chest wall allowing both direct trauma and deceleration as possible mechanisms of trauma . In our case the patient suffered blunt chest trauma as his car collided with a moose. He experienced dissection of the middle part of the LAD (Figure 1). Both coronary artery dissection, intimal tear, plaque rupture or epicardial hematoma might lead to AMI after blunt trauma. However, in 12 published cases of traumatic AMI the coronary angiograms were completely normal . Spasm or lysis of a thrombus might explain AMI in these cases. It should be noted that AMI also has been reported after mild trauma [13, 17, 18].
In traumatic AMI, the diagnosis might be masked by chest pain originating from other thoracic injuries. ECG may be normal , but usually demonstrates abnormalities [15, 16, 19]. Our patient presented with right bundle branch block (Figure 2). In the case of AMI from coronary artery occlusion, ST-elevations, R-loss and Q-wave development are likely to occur [5, 8, 9]. In our patient, ST-elevations were first recognized sixteen hours after the trauma in the anterior leads (Figure 3). Prior to this our patient developed hypotension (80/50 mmHg) and compromised peripheral circulation. Echocardiography demonstrated marked apical akinesia and slightly dilated left ventricle with ejection fraction (EF) of approximately 30%. There were no signs of valvular injury or hemopericardium. The condition was in our case first perceived as severe cardiac contusion. Echocardiography may show regional motion abnormalities in case of ischemia and AMI [5, 9, 14, 15]. It might also demonstrate hemopericardium and valvular insufficiency , if present. Troponin is a sensitive marker of cardiac injury and may be elevated in traumatic coronary artery dissection [8, 9]. The pathological increase may develop several hours after admission . In our patient troponin-T was slightly elevated the first hours after admission and reached a maximum of 11.5 μg/L 30 hours after the accident (Figure 4). Both coronary artery occlusion and dissection without occlusion may be demonstrated by a coronary angiogram . If coronary angiography and revascularization is performed early after onset of ischemia, AMI may be avoided . The time lapse from injury to coronary artery occlusion may vary. AMI has been reported to occur immediately and up to five weeks after trauma [5, 11, 22].
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.
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.
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.
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.
Parmley LF, Manion WC, Mattingly TW: Nonpenetrating traumatic injury of the heart. Circulation. 1958, 18: 371-396.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Westaby S, Drossos G, Giannopoulos N: Posttraumatic coronary artery aneurysm. Ann Thorac Surg. 1995, 60: 712-713. 10.1016/0003-4975(95)00342-I.
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.
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.
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.
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.
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.
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.
The authors declare that they have no competing interests.
All authors contributed in the treatment of the patient and in the preparation of the manuscript.
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Bjørnstad, J.L., Pillgram-Larsen, J. & Tønnessen, T. Coronary artery dissection and acute myocardial infarction following blunt chest trauma. World J Emerg Surg 4, 14 (2009) doi:10.1186/1749-7922-4-14
- Acute Myocardial Infarction
- Acute Myocardial Infarction
- Left Anterior Descend
- Coronary Artery Occlusion
- Coronary Artery Aneurysm