Spontaneous coronary artery dissection: a rare threat to young women

Spontaneous coronary artery dissection not associated with underlying coronary artery disease is rare. When the dissection does occur, it most often is manifested as an acute ST-elevation myocardial infarction in young women. Although the condition can occur in men, most often it involves women who are in their third trimester of pregnancy or the early postpartum period or are engaging in vigorous exercise. Because little is known about spontaneous coronary artery dissection in this population of women, recommendations for treatment are the same as for treatment of acute myocardial infarction associated with atherosclerotic coronary disease.     

Coronary artery occlusion following blunt chest trauma: a case report and review of the literature

Blunt chest trauma causing coronary artery occlusion and myocardial infarction is a rare but potentially fatal condition. We present the case of a healthy 29-year-old man who developed a myocardial infarction due to complete occlusion of the proximal right coronary artery following blunt chest trauma. A review of the literature found 63 cases of previously healthy patients under 40 years of age who developed coronary artery occlusion following blunt chest trauma; diagnosis in all cases had been proven by angiography or during autopsy. The presentation, results of electrocardiography and echocardiography and laboratory findings of these patients are described.     

Visualization of a large ventricular aneurysm in a young man by 16-slice multi-detector row spiral computed tomography before successful surgical treatment

Left ventricular (LV) aneurysm after myocardial infarction without any clinical symptoms is a rare complication of coronary artery disease. In most cases, especially in young people, this complication is diagnosed too late, after rupture into the pericardial cavity has occurred. Here we present the successful surgical repair of a large LV aneurysm in a 35-year-old man. We could visualize this aneurysm and the coronary arteries non-invasively by contrast-enhanced 16-slice multi-detector row spiral computed tomography (MDCT).     

Thrombosed right coronary artery aneurysm presenting as a myocardial mass

A coronary artery aneurysm is defined as coronary dilatation that exceeds the diameter of normal adjacent artery segments, or is 1.5 times the diameter of the largest coronary artery. Coronary artery aneurysms are rare with an incidence of between 1.5% to 5%. The aneurysm is caused by destruction of the vessel media, thinning of the arterial wall, increased wall stress, and progressive dilatation of a segment of the coronary artery. The most common cause is atherosclerotic coronary artery disease. These aneurysms occasionally rupture but more commonly develop thrombus and hematoma leading to the appearance of the presence of an intramyocardial mass. We present the case of a 60-year-old man with hypertension who presented with a mass that was identified initially by transthoracic echocardiography in the setting of an inferior wall myocardial infarction, which was later recognized to be a thrombosed right coronary artery aneurysm.     

Association of serum immunoglobulin G (IgG) levels against two periodontal pathogens and prothrombotic state: a clinical pilot study

Normal pregnancy corresponds to a procoagulant state. Acute myocardial infarction during pregnancy is rare, yet considering the low non-pregnant risk score of childbearing women it is still surprisingly frequent. We report a case of postpartum recurrent non-ST elevation myocardial infarction in a 40-year-old caucasian woman with essential thrombocythaemia in the presence of a positive JAK-2 mutation and an elevated anti-cardiolipin IgM antibody titer. In the majority of cases of myocardial infarction in pregnancy or in the peripartal period, atherosclerosis, a thrombus or coronary artery dissection is observed. The combination of essential thrombocythaemia and elevated anti-cardiolipin IgM antibody titer in the presence of several cardiovascular risk factors seems to be causative in our case. In conclusion, with the continuing trend of childbearing at older ages, rare or unlikely conditions leading to severe events such as myocardial infarction must be considered in pregnant women.     

Left atrial hematoma complicating inferior myocardial infarction.

Intramyocardial dissecting hematoma after myocardial infarction is a rare condition. Previous reports have documented that these hematomas form almost exclusively in the myocardium adjacent to the culprit coronary lesion. We report a case of coexistent intramyocardial dissecting hematoma and ventricular rupture that arose as a consequence of a distal right coronary artery occlusion. Unusually, there was a very long dissection plane, which crossed the atrioventricular groove, with the hematoma manifesting on the opposite side of the heart (left atrium) to the infarcted myocardium (inferior wall).     

冠状动脉超声显像研究川崎病冠状动脉瘤：十二年回顾分析

1984年～1996年间应用冠状动脉超声显像研究川崎病502例，检出冠状动脉瘤（CAA）70例（13．9％），冠状动脉内径＞4mm（CA／AO＞0．30），呈校形扩张，51例（72．8％）1年好转。14例巨大CAA（BCAA）内径＞8mm（CA／AO＞0．60），回缩困难，经2～5年稍好转。7例并发冠状动脉血栓，2例并发心肌梗塞，4例并发腋动脉瘤，10例以心肌断层显像99mTC－MIBI对照研究，显示心肌灌注异常。1例CAA患儿因急性心肌梗塞死亡。冠状动脉超声显像用于诊断和随访川崎病冠状动脉瘤具有方便、迅速、直观、定位准确的优点，值得临床推广使用。     

Acute coronary syndrome in pregnant women

The purpose of this article is to review the available information on the pathophysiology, diagnosis, treatment and prognosis of acute coronary syndromes (ST-elevation myocardial infarction [STEMI] and non-ST-elevation myocardial infarction [NSTEMI]) during all stages of pregnancy. We searched the English-language literature indexed in MEDLINE, Scopus and EBSCO host research databases from 1980 through to August 2010 using the indexing terms ‘pregnancy’, ‘ante-,peri-, and postpartum’, ‘acute coronary syndrome’, ‘myocardial infarction’, ‘STEMI’ and ‘NSTEMI’. Symptomatic coronary artery disease is still infrequent in women of childbearing age, but the recent increase in its prevalence in pregnancy has been attributed to the modern trend of childbearing in older years because many young working women are postponing having children. Although rare, acute pregnancy-related MI is a devastating event that may claim the life of a mother and her fetus. The incidence of MI is estimated at 0.6–1 per 10,000 pregnancies. The case fatality rate has been reported to be 5–37%. Owing to the rarity of the event, information related to MI in pregnancy is derived from case reports and, therefore, is subject to considerable reporting bias. Treatment needs to be prompt and urgent because of the very high mortality rate. Current guidelines for the diagnosis and treatment of MI should be expanded to include pregnancy-related MI. Screening and management of cardiovascular risk factors should be achieved before pregnancy.     

Reversible segmental myocardial dysfunction in septic shock

We report two septic-shock patients who had ECG and echocardiographic changes consistent with myocardial infarction but no evidence of coronary artery disease or myocardial injury at autopsy. The segmental myocardial dysfunction completely resolved in one patient. Because septic shock can cause segmental myocardial dyskinesis, ECG and echocardiographic data may be misleading and should be interpreted cautiously.     

Two- and three-dimensional transesophageal echocardiographic diagnosis of intramyocardial dissecting hematoma after myocardial infarction.

The echocardiographic findings of an intramyocardial dissecting hematoma that formed after an extensive acute myocardial infarction of the anterior wall of a 42-year- old man are described. Serial transesophageal studies were used to construct 3-dimensional images that clarified the participation of various myocardial layers that surrounded the dissecting hematoma. The patient was successfully treated with intra-aortic balloon counterpulsation and subsequently coronary artery bypass grafting. Intramyocardial dissecting hematoma is a rare complication of acute infarction; differential diagnosis must be made with pseudoaneurysm by establishing integrity of epicardium and with intracavitary thrombosis by identifying the endomyocardial layer surrounding the neoformation and associated wall movement.     

冠状动脉扩张的64排螺旋CT表现及临床意义

目的探讨冠状动脉扩张的64排螺旋CT表现及临床意义。方法收集2009年10月—2010年12月之间经MDCT诊断为冠状动脉扩张的患者13例,分析病变发生的部位、大小(横径)、病变范围(长度)、血管腔内有无血栓形成、数目以及是否合并心肌缺血。结果在13例患者中共有15个节段可以评价,其中病变发生在单支血管者11例,病变发生在两支冠状动脉者2例。弥漫性冠状动脉扩张10例,局限性冠状动脉扩张3例(2例为球形动脉瘤,1例为梭形动脉瘤)。扩张率为1.5~2.8,发生部位为:RCA 7例(7/15),LM 1例(1/15),LAD 3例(3/15),LCX 3例(3/15),Ramus 1例(1/15);9例伴硬化斑块形成,1例缺血性心脏病。结论冠状动脉扩张的多排螺旋CT表现具有其特征性,64排螺旋CT冠状动脉造影是诊断冠状动脉扩张的一种良好的手段。     

Acute Myocardial Infarction With Sumatriptan: A Case Report and Review of the Literature

We report a case of myocardial infarction associated with the use of sumatriptan and review the literature regarding similar cases. A 54-year-old woman with a history of migraine without aura, mild arterial hypertension, depression, and no history of coronary artery disease was admitted to our hospital for acute myocardial infarction, 30 minutes after using 6 mg of subcutaneous sumatriptan. Coronary angiography performed several days later revealed a normal coronary arterial system. Although at discharge the patient was advised to permanently avoid triptans, she continued the use of oral sumatriptan at low dosage (25-50 mg) without any problems.     

Spontaneous coronary artery dissection

A 45-year-old female athlete with no history of cardiovascular disease or coronary risk factors presented with a non-ST-segment elevation myocardial infarction due to spontaneous right coronary artery dissection. She was treated medically with resolution of her symptoms. Repeat angiography due to recurrent exertional chest discomfort showed TIMI-3 flow and no evidence of dissection. Intravascular ultrasound documented discrete areas of resolving hematoma, but no dissection flap or impingement of the lumen >30%. A coronary computed tomography 6 months later revealed absence of any vascular abnormalities. This rare but potentially lethal condition should be considered in the differential diagnosis of young patients with chest pain, myocardial infarction, or sudden cardiac death, especially if it involves women either in the peripartum period or those using oral contraceptives, or patients without evidence of coronary atherosclerosis or traditional cardiovascular risk factors.     

Congenital absence of the right coronary artery with acute myocardial infarction: report of two cases and review of the literature

Congenital absence of the right coronary artery (RCA) is a rare coronary anomaly. Few cases of this condition have been reported. Congenital absence of the RCA is considered as a benign anomaly. However, in certain cases, these patients may develop life-threatening clinical complications that include acute myocardial infarction, stroke, or sudden death. We report two patients who were diagnosed with congenital absence of the RCA and presented with acute myocardial infarction. We discuss our experience in diagnosis and treatment of this disease. Congenital absence of the RCA with acute myocardial infarction is an uncommon clinical emergency. Therefore, early detection, correct diagnosis, and appropriate treatment are important.     

Pathological features of witnessed out-of-hospital cardiac arrest presenting with ventricular fibrillation.

OBJECTIVES: To determine which characteristic pathological features are predictive of the presenting rhythm and survival in victims of community cardiac arrest. DESIGN: Case-controlled retrospective autopsy study. SETTING: County of Nottinghamshire with a total population of 993 914 and an area of 2183 square kilometers. SUBJECTS: Between January 1, 1991 and December 31, 1994, 1535 witnessed cardiac arrests attended by the Nottinghamshire Ambulance Service, of which 1083 had an autopsy performed. RESULTS: Ischaemic heart disease accounted for 72.3% of cases with a further 3.6% of deaths from other cardiac causes and the remainder from non-cardiac causes. Old healed myocardial infarction was present in 39.4%, and visible fresh occlusive thrombus was found in 23.8% of cases overall. Logistic regression analysis of deaths from cardiac causes revealed that younger age (odds ratio of 0.98 (95% CI 0.97-0.99)), two vessel coronary artery disease (odds ratio of 1.65 (95% CI 1.08-2.52)) and heart weight greater than 500 grams (odds ratio of 1.56 (95% CI 1.12-2.17)) were found to be independent predictors of developing ventricular fibrillation compared to other rhythms of arrest. Being male, visible occlusive thrombus and having survived a previous myocardial infarction were found not to be independent variables. There were no outstanding pathological features in the 31 patients who survived to hospital admission and subsequently died, compared with non-survivors who were considered to have died from a cardiac cause. CONCLUSIONS: Among those who had a witnessed out-of-hospital cardiac arrest from a cardiac cause, increasing heart weight (the most likely cause of which is left ventricular hypertrophy), younger age and two vessel coronary artery disease appear to be much more important pathological features in the development of ventricular fibrillation than a previous myocardial infarction and fresh visible occlusive thrombus.     

70例心脏性猝死患者的临床尸检病理分析

目的探讨心脏性猝死(SCD)的临床特点、病理基础及致死因素,从而为防治SCD提出有效措施。方法回顾性分析我院70例SCD的临床尸检病理资料。结果70例SCD患者中,冠心病猝死43例,主动脉夹层动脉瘤破裂者13例,心肌炎6例,心肌病3例,肺栓塞5例。冠心病猝死43例中,陈旧性心肌梗死(OMI)7例,OMI 急性心肌梗死(AMI)27例,单纯AMI7例。尸检发现冠状动脉粥样硬化Ⅳ级狭窄者33例,其中多支病变者36例。结论SCD病程短骤、凶险,以老年男性多见,冠心病占首位。冠状动脉多支重度粥样硬化性狭窄是重要的病理基础。尽早防治冠心病、高血压,改善心肌供血是预防SCD的根本措施。     

Acute myocardial infarction from embolization of Lambl's excrescences: A case report

While coronary artery embolism remains an infrequent cause of myocardial infarction (MI), it may present in patients at otherwise low risk for coronary artery disease. When clinicians apply typical risk stratification in these cases, they may be led away from a full evaluation for acute coronary syndrome (ACS). A diagnosis of MI in an otherwise healthy patient should prompt consideration of embolic sources, including Lambl's excrescences (LEs), and echocardiographic evaluation may be necessary to make a final diagnosis. We present a case of LEs in an otherwise healthy 43-year-old male presenting with chest pain and elevated cardiac enzymes, and also review the cases of this rare event found in the literature.     

Multifocal coronary artery myocardial bridging involving the right coronary and left anterior descending arteries detected by ECG-gated 64 slice multidetector CT coronary angiography

Myocardial bridging is a congenital condition in which a segment of a major epicardial coronary artery has an intramyocardial course. Myocardial bridging is usually confined to a single vessel (typically the mid segment of the left anterior descending artery) and is usually asymptomatic, however, bridging may be associated with chest pain, myocardial infarction, or sudden cardiac death. While more commonly identified at autopsy, myocardial bridging is occasionally diagnosed by coronary angiography with identification of concomitant myocardial bridging involving both the left and right coronary arteries appearing to be uncommon. We present three patients presenting with atypical chest pain symptoms in whom concomitant right coronary artery and left anterior descending artery myocardial bridging was identified by ECG gated multidetector computed tomography (MDCT).     

Cardiac cephalalgia closely associated with acute myocardial infarction

Cardiac cephalalgia is an uncommon symptom occurring in coronary artery disease. It is difficult to identify cardiac cephalalgia and link it to coronary artery disease because these patients present with only a headache and no typical symptoms of angina, such as chest pain, radiating pain, or chest tightness. Currently, the diagnostic value of cardiac cephalalgia in acute myocardial infarction is still under debate. We here report a case of cardiac cephalalgia. An 83-year-old woman with a severe headache lasting 6 h was diagnosed with acute myocardial infarction. ST elevation and severe stenosis of the right coronary artery were observed. Passage of the guide wire and radiocontrast agent increased the intensity of the headache, which disappeared once the right coronary artery was opened. As of one month into follow-up, the headache had not recurred. These observations strongly indicate a close association between cardiac cephalalgia and acute myocardial infarction, and they could help diagnose acute myocardial infarction related to headaches.     

The effects of various factors on long-term outcomes of non-stable stenocardia

The article presents the results of one-year observation of 472 patients who experienced non-stable stenocardia in 2003-2004. During this period, exacerbation of coronary artery disease with or without acute coronary catastrophe was noted in every third patient. Thirty-three cases of acute coronary pathology were registered. Year lethality was 27.3%, with acute myocardial infarction as the leading cause of death. By step-wise diagnostic regression method it was proved that old myocardial infarction was the only factors that had a significant negative effect on the long-term prognosis of non-stable stenocardia.