1
|
Monin A, Didier R, Leclercq T, Chagué F, Rochette L, Danchin N, Zeller M, Fauchier L, Cochet A, Cottin Y. Coronary artery embolism and acute coronary syndrome: A critical appraisal of existing data. Trends Cardiovasc Med 2024; 34:50-56. [PMID: 35868593 DOI: 10.1016/j.tcm.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 10/17/2022]
Abstract
The occurrence of coronary artery embolism (CE) has been associated with various clinical conditions, including aortic and mitral prosthetic heart valve implantation, atrial fibrillation (AF), dilated cardiomyopathy, neoplasia, infective endocarditis, atrial septal defect, cardiac tumors, and hypercoagulable states. CE is also a rare cause of myocardial infarction (MI), with a prevalence of about 5%, a figure probably underestimated. The purpose of this article was to determine the current state of knowledge on acute coronary syndrome (ACS) related to CE. We thus performed a comprehensive structured literature search of the MEDLINE database for articles published between 1 January 1990 and 31 December 2021. The diagnosis of CE remains difficult despite the currently used Shibata classification, which is based on major criteria, including angiographic characteristics: globular filling defects, saddle thrombi or multiple filling defects and absence of atherosclerosis in the coronary arteries. Suspected or confirmed CE requires the identification of an etiology. There are only two published series on CE, including about 50 cases each. The three main causes in these series were: 1) atrial fibrillation (73% vs 28.3%), 2) cardiomyopathy (9.4% vs 25%) and 3) malignancy (9.6% vs 15.1%). Finally, 26.3% of the MI patients with CE had no identifiable cause of CE. When anatomically possible, analyzing the thrombus after thrombectomy may help. MI due to CE requires systematic assessment of other locations, i.e. multiple coronary and extracardiac locations. Simultaneous systemic embolization to the brain (67%), limbs (25%), kidneys (25%) or spleen (4%) is frequent, occurring in approximately 25% of CE-related MI. In the setting of acute MI, CE is associated with significant morbidity and mortality. Coronary artery thromboembolism is a rare, non-atherosclerotic, cause of ACS, and prospective studies are needed to evaluate a systematic diagnostic approach and personalized therapeutic strategies.
Collapse
Affiliation(s)
- Antoine Monin
- Department of Cardiology, University Teaching Hospital of Dijon Bourgogne, Dijon, France
| | - Romain Didier
- Department of Cardiology, University Teaching Hospital of Dijon Bourgogne, Dijon, France
| | - Thibault Leclercq
- Department of Cardiology, University Teaching Hospital of Dijon Bourgogne, Dijon, France
| | - Frédéric Chagué
- Department of Cardiology, University Teaching Hospital of Dijon Bourgogne, Dijon, France
| | - Luc Rochette
- PEC2, EA 7460, University of Burgundy, Dijon, France
| | - Nicolas Danchin
- Department of Cardiology, University Teaching Hospital of Georges Pompidou, Paris, France
| | - Marianne Zeller
- Department of Cardiology, University Teaching Hospital of Dijon Bourgogne, Dijon, France; PEC2, EA 7460, University of Burgundy, Dijon, France
| | - Laurent Fauchier
- Department of Cardiology, University Teaching Hospital of Trousseau and François Rabelais University, Tours, France
| | - Alexandre Cochet
- Department of Magnetic Resonance Imaging, University Teaching Hospital of Dijon Bourgogne, Dijon, France
| | - Yves Cottin
- Department of Cardiology, University Teaching Hospital of Dijon Bourgogne, Dijon, France.
| |
Collapse
|
2
|
Lodeen H, Esmati S, Okan T, Arastu A, Vilendecic D, Singh G, Mangla A, Moshayedi P, Lasic Z. The Simultaneous Occurrence of Acute ST-Elevation Myocardial Infarction, Acute Ischemic Stroke, and Pulmonary Embolism. Cureus 2023; 15:e44222. [PMID: 37767245 PMCID: PMC10522405 DOI: 10.7759/cureus.44222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/29/2023] Open
Abstract
Acute ST-elevation myocardial infarction (STEMI), acute ischemic stroke (AIS), and acute pulmonary embolism (PE) are life-threatening conditions, each posing a high risk of morbidity and mortality. When all three of these acute conditions occur simultaneously, the overall prognosis for the patient becomes considerably worse. We report a case of a 70-year-old woman who presented to the emergency department (ED) with a triad of acute STEMI, AIS, and PE as a consequence of atherosclerotic heart disease, atrial fibrillation, and a prolonged transatlantic flight. The diagnoses were promptly confirmed through emergent coronary and cerebral angiography, along with a computerized tomography pulmonary angiogram (CTPA). The patient underwent a combination of medical therapy and endovascular thrombectomy. However, she later developed a subarachnoid hemorrhage and eventually progressed to brain death.
Collapse
Affiliation(s)
- Homayoon Lodeen
- Internal Medicine, Jamaica Hospital Medical Center, New York, USA
| | - Saliman Esmati
- Internal Medicine, Jamaica Hospital Medical Center, New York , USA
| | - Tetyana Okan
- Internal Medicine, Jamaica Hospital Medical Center, New York, USA
| | - Azeem Arastu
- Internal Medicine, Jamaica Hospital Medical Center, New York, USA
| | - Dora Vilendecic
- Internal Medicine, Jamaica Hospital Medical Center, New York, USA
| | - Gagandeep Singh
- Cardiology, Northwell Health Lenox Hill Hospital, New York, USA
| | - Aditya Mangla
- Cardiology, Northwell Health Lenox Hill Hospital, New York, USA
| | - Pouria Moshayedi
- Interventional Neurology, Jamaica Hospital Medical Center, New York, USA
| | - Zoran Lasic
- Cardiology, Northwell Health Lenox Hill Hospital, New York, USA
| |
Collapse
|
3
|
Acute myocardial infarction related to coronary artery embolism: A systematic cardiac and cerebral magnetic resonance imaging study. Arch Cardiovasc Dis 2022; 115:457-466. [DOI: 10.1016/j.acvd.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/11/2022] [Accepted: 05/16/2022] [Indexed: 11/30/2022]
|
4
|
Cardio-cerebral infarction in left MCA strokes: a case series and literature review. Neurol Sci 2021; 43:2413-2422. [PMID: 34590206 PMCID: PMC8480750 DOI: 10.1007/s10072-021-05628-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/23/2021] [Indexed: 10/27/2022]
Abstract
The objective of this manuscript is to describe the challenges of Cardio-Cerebral Infarction (CCI) treatment and to highlight the variable approaches in management. CCI is a rare clinical presentation of simultaneous acute ischemic stroke (AIS) and acute myocardial infarction (AMI) and poses a therapeutic challenge for practitioners. Each disease requires timely intervention to prevent irreversible damage; however, optimal management remains unclear. We describe three cases of CCI. All three patients presented with symptomatic left MCA (M1) occlusion, with ST elevation myocardial infarction (STEMI) and left ventricular apical thrombus. Fibrinolysis and mechanical thrombectomy (MT) were discussed in all cases, but only one patient received alteplase (0.9 mg/kg) and none underwent MT. Percutaneous intervention (PCI) was done in only one case. The two patients that did not receive thrombolysis were treated with modified therapeutic heparin (no bolus), and all received antiplatelet therapy. Ultimately, all three patients passed away. CCI poses a clinical challenge for physicians including (1) optimal strategies to enable swift mechanical reperfusion to both the brain and myocardium; (2) difference in dosage of thrombolytics for AIS versus AMI; (3) risk of symptomatic intracerebral hemorrhage following administration of anticoagulation and/or antiplatelet therapy; and (4) caution with use of thrombolytics in the setting of acute STEMI due to the risk of myocardial rupture. In the absence of high quality evidence and clinical guidelines, treatment of CCI is highly individualized.
Collapse
|
5
|
Detection of Myocardial Infarction by Cardiac Magnetic Resonance in Embolic Stroke Related to First Diagnosed Atrial Fibrillation. J Stroke Cerebrovasc Dis 2021; 30:105753. [PMID: 33845423 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Elevated troponin levels are found in a significant number of patients who are diagnosed with acute embolic stroke (AES) after first diagnosed atrial fibrillation (AF). These myocardial injuries, which are known as cardiocerebral infarction (CCI), are potentially caused by coronary embolism and correspond to simultaneous cardiac and cerebral embolisms. However, this severe condition remains poorly understood. In this prospective study, we aimed to investigate the prevalence and the cardiac magnetic resonance (CMR) characteristics of CCI. MATERIALS AND METHODS Consecutive patients with first diagnosed AF hospitalized for AES in a neurovascular intensive care unit from 2019 to 2020 were included. Troponin Ic kinetic were measured <72 h, MRI and coronary angiography or CT scan were performed <7 days after admission. Patients with significant coronary lesions were excluded. RESULTS During the study period, 1150 patients with strokes were hospitalized in the neurovascular intensive care unit (ICU). Of these patients, 955 had an ischemic stroke and 97 had a transient ischemic attack. Among the 44 patients with AES and with first diagnosed AF, 34 patients underwent CMR and CMR analysis identified 12 MI. A significant rise in troponin (>0.10 µg/L) was observed in 35% of the total population (12/34 patients). More specifically, a rise was seen in 23% of the AES without MI group, 58% of the AES with MI. In addition, coronary embolism was identified in 3 patients who underwent coronary angiography (3/12) and MI was often (30%) localized in infero-latero-medial and infero-apical segments. Most AES were localized in the superficial sylvian territory. CONCLUSION We found a high prevalence of CMR-confirmed double embolization sites in the acute phase of an embolic stroke. Further studies are required to better characterize the pathophysiology, clinical course and prognostic value of CCI. Moreover, optimal management strategies, including antiplatelet therapy, remain to be determined.
Collapse
|
6
|
Mione V, Yao H, Laurent G, Zeller M, Fauchier L, Cottin Y. Simultaneous cardiocerebral embolization in patients with atrial fibrillation. Arch Cardiovasc Dis 2020; 113:821-827. [DOI: 10.1016/j.acvd.2020.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 11/15/2022]
|
7
|
Katsuki M, Katsuki S. A case of cardiac tamponade during the treatment of simultaneous cardio-cerebral infarction associated with atrial fibrillation - Case report. Surg Neurol Int 2019; 10:241. [PMID: 31893142 PMCID: PMC6911677 DOI: 10.25259/sni_504_2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 11/23/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Simultaneous cerebral and myocardial infarction is called cardio-cerebral infarction (CCI). It is a rare condition, and its management strategy has yet to be determined. We report a case of cardiac tamponade during the treatment of CCI associated with atrial fibrillation. Case Description: A 72-year-old man presented with loss of consciousness after chest discomfort. He had taken rivaroxaban for paroxysmal atrial fibrillation. Twelve-lead electrocardiography showed ST elevation at II, III, and aVF. His National Institutes of Health Stroke Scale was 29. We diagnosed him with synchronous cardioembolic stroke and acute myocardial infarction due to atrial fibrillation. The coronary angiography revealed distal occlusion in the posterior descending branch of the right coronary artery, and overall myocardial perfusion seemed sufficient. The diffusion-weighted image showed hyperintense lesions at the cerebellum, and magnetic resonance angiography did not reveal the flow of the basilar artery. The patient’s NIH score improved immediately, so we did not perform intravenous tissue plasminogen activator (IV-tPA) administration nor endovascular treatment. Heparin administration was started. After 38 h from the onset, he suffered from hydrocephalus, and cerebral ventricular drainage was performed. Subsequently, circulatory dynamics worsened, and he was diagnosed with cardiac tamponade. Emergency pericardiotomy was performed, and he has been taking intensive care. Conclusion: Some cases with CCI treated with IV-tPA and endovascular intervention were reported, but the treatment strategy should be still discussed multidisciplinary. Especially, the administration of antithrombotic drugs for CCI should be carefully performed because fatal hemorrhage such as cardiac tamponade can occur.
Collapse
Affiliation(s)
| | - Shigemi Katsuki
- Katsuki Clinic, 21-3, Koganedai, Higashi-ward, Niigata, Japan
| |
Collapse
|
8
|
Akinseye OA, Shahreyar M, Heckle MR, Khouzam RN. Simultaneous acute cardio-cerebral infarction: is there a consensus for management? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:7. [PMID: 29404353 DOI: 10.21037/atm.2017.11.06] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Acute ischemic stroke (AIS) and acute myocardial infarction (AMI) are both life-threatening medical conditions with narrow therapeutic time-window that carry grave prognosis if not addressed promptly. The acute management of both condition is well documented in the literature, however the management of a simultaneous presentation of both AIS and AMI is unclear. A delayed intervention of one infarcted territory for the other may result in permanent irreversible morbidity or disability, and even death. In addition, the use of antiplatelet and anticoagulants that are inherently part of an AMI management may increase the risk for hemorrhagic conversion associated with intravenous thrombolysis used in AIS, and the use of a thrombolytic in AIS increases the risk of cardiac wall rupture in the setting of an AMI. Despite this ambiguity, there is no clear evidence-based guideline or clinical studies that have addressed the optimal management of this rare co-occurrence. This review paper examines the existing literature on the management of simultaneous acute cardio-cerebral infarction (CCI) and highlights the existing challenge to management.
Collapse
Affiliation(s)
- Oluwaseun A Akinseye
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Muhammad Shahreyar
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mark R Heckle
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Rami N Khouzam
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| |
Collapse
|
9
|
Tokuda K, Shindo S, Yamada K, Shirakawa M, Uchida K, Horimatsu T, Ishihara M, Yoshimura S. Acute Embolic Cerebral Infarction and Coronary Artery Embolism in a Patient with Atrial Fibrillation Caused by Similar Thrombi. J Stroke Cerebrovasc Dis 2016; 25:1797-1799. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.055] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 01/14/2016] [Accepted: 01/31/2016] [Indexed: 01/19/2023] Open
|
10
|
Gagliardi L, Guerbaai RA, Marlière S, Bouvaist H, Ennezat PV. Coronary embolization following electrical cardioversion in a patient treated with dabigatran. Int J Cardiol 2014; 175:571-2. [DOI: 10.1016/j.ijcard.2014.05.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 05/12/2014] [Indexed: 11/29/2022]
|
11
|
Hashimoto O, Sato K, Numasawa Y, Hosokawa J, Endo M. Simultaneous onset of myocardial infarction and ischemic stroke in a patient with atrial fibrillation: Multiple territory injury revealed on angiography and magnetic resonance. Int J Cardiol 2014; 172:e338-40. [DOI: 10.1016/j.ijcard.2013.12.312] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 12/30/2013] [Indexed: 10/25/2022]
|
12
|
Kim HL, Seo JB, Chung WY, Zo JH, Kim MA, Kim SH. Simultaneously Presented Acute Ischemic Stroke and Non-ST Elevation Myocardial Infarction in a Patient with Paroxysmal Atrial Fibrillation. Korean Circ J 2013; 43:766-9. [PMID: 24363753 PMCID: PMC3866317 DOI: 10.4070/kcj.2013.43.11.766] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 05/30/2013] [Accepted: 06/14/2013] [Indexed: 11/12/2022] Open
Abstract
Although atrial fibrillation is the most frequent cause of embolic stroke, coronary embolism from atrial fibrillation is a very rare cause of acute myocardial infarction. Therefore, simultaneously presented acute ischemic stroke and acute myocardial infarction due to atrial fibrillation in the same patient has not been documented. The present report describes the case of a 58-year-old man with paroxysmal atrial fibrillation who initially presented with a large cerebral infarction due to embolic occlusion of the left middle cerebral artery. Four hours after the diagnosis of cerebral embolism, he was subsequently diagnosed with acute myocardial infarction due to concurrent coronary embolism. He underwent successful coronary revascularization with a drug-eluting stent. The possibility of combined coronary embolism as a rare etiology should be kept in mind when a patient with acute embolic stroke presents, especially when there is evidence of acute myocardial infarction.
Collapse
Affiliation(s)
- Hack-Lyoung Kim
- Cardiovascular Center, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jae-Bin Seo
- Cardiovascular Center, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Woo-Young Chung
- Cardiovascular Center, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Joo-Hee Zo
- Cardiovascular Center, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Myung-A Kim
- Cardiovascular Center, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Sang-Hyun Kim
- Cardiovascular Center, Seoul National University Boramae Medical Center, Seoul, Korea
| |
Collapse
|
13
|
Larsen AI, Nilsen DWT, Yu J, Mehran R, Nikolsky E, Lansky AJ, Caixeta A, Parise H, Fahy M, Cristea E, Witzenbichler B, Guagliumi G, Peruga JZ, Brodie BR, Dudek D, Stone GW. Long-term prognosis of patients presenting with ST-segment elevation myocardial infarction with no significant coronary artery disease (from the HORIZONS-AMI trial). Am J Cardiol 2013; 111:643-8. [PMID: 23261001 DOI: 10.1016/j.amjcard.2012.11.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 11/14/2012] [Accepted: 11/14/2012] [Indexed: 11/16/2022]
Abstract
The clinical features and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and no significant coronary artery disease (CAD) have not been well studied. We examined the outcomes of patients with STEMI in the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial according to the presence or absence of significant CAD. "No-CAD" was defined by the absence of any lesion with a diameter stenosis of ≥30% on quantitative coronary angiography of the baseline coronary angiogram. Of 3,602 patients, 127 (3.5%) had no-CAD. Of these, 86 (67.7%) had angiographically normal coronary arteries, and 41 (32.3%) had mild disease (diameter stenosis <30%). Eight patients had previously been treated with coronary artery bypass grafting. Compared to patients with CAD, patients with no-CAD were younger, had a lower body mass index, were more frequently black, had a lower prevalence of smoking and previous angina, and had a greater left ventricular ejection fraction. Cardiac enzymes were elevated in fewer patients with no-CAD than in those with CAD (63.2% vs 98.7%, p <0.001). At 3 years of follow-up, the patients with no-CAD versus CAD had lower rates of major adverse cardiovascular events (7.7% vs 22.2%, p = 0.002), net adverse clinical events (major adverse cardiovascular events or major bleeding not related to coronary artery bypass grafting, 12.5% vs 26.9%, p = 0.005), and postprocedure coronary revascularization (0% vs 19.5%, p <0.001). The differences in the rates of death or reinfarction, stroke, and major bleeding were not statistically significant. In conclusion, 3.5% of patients with STEMI had no significant CAD. The 3-year prognosis for these patients was favorable compared to that of patients with STEMI and with obstructive CAD.
Collapse
Affiliation(s)
- Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|