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Ceasovschih A, Mantzouranis E, Dimitriadis K, Sorodoc V, Vlachakis PK, Karanikola AE, Theofilis P, Koutsopoulos G, Drogkaris S, Andrikou I, Valatsou A, Lazaros G, Sorodoc L, Tsioufis K. Coronary artery thromboembolism as a cause of myocardial infarction with non-obstructive coronary arteries (MINOCA). Hellenic J Cardiol 2024; 79:70-83. [PMID: 38825235 DOI: 10.1016/j.hjc.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/09/2024] [Accepted: 05/03/2024] [Indexed: 06/04/2024] Open
Abstract
Acute myocardial infarction (AMI) usually represents the clinical manifestation of atherothrombotic coronary artery disease (CAD) resulting from atherosclerotic plaque rupture. However, there are cases in which coronary angiography or coronary computed tomography angiography reveals patients with acute coronary syndrome with non-obstructive CAD. This clinical entity is defined as myocardial infarction with non-obstructive coronary arteries (MINOCA) and often considered as a clinical dynamic working diagnosis that needs further investigations for the establishment of a final etiologic diagnosis. The main causes of a MINOCA working diagnosis include atherosclerotic, non-atherosclerotic (vessel-related and non-vessel-related), and thromboembolic causes This literature review aimed to investigate the major thromboembolic causes in patients presenting with MINOCA regarding their etiology and pathophysiologic mechanisms, as well as diagnostic and treatment methods.
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Affiliation(s)
- Alexandr Ceasovschih
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, Iasi, Romania
| | - Emmanouil Mantzouranis
- First University Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Kyriakos Dimitriadis
- First University Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece.
| | - Victorita Sorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, Iasi, Romania
| | - Panayotis K Vlachakis
- First University Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Panagiotis Theofilis
- First University Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - George Koutsopoulos
- First University Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotirios Drogkaris
- First University Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Andrikou
- First University Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Angeliki Valatsou
- First University Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - George Lazaros
- First University Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Laurentiu Sorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, Iasi, Romania
| | - Konstantinos Tsioufis
- First University Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
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Coronary Embolism and Myocardial Infarction: A Scoping Study. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2020; 8:31-43. [PMID: 32775621 PMCID: PMC7410523 DOI: 10.12691/ajmcr-8-2-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Coronary embolism is a cause of acute myocardial infarction (AMI)in which obstructive foci enter the coronary circulation, block normal blood flow and precipitate ischemia. Precise studies focusing on patient population affected, pathophysiological mechanisms, and treatment strategies are scanty, in spite of a reported prevalence estimated at 2.9%. As the understanding of myocardial infarction without evidence of coronary artery disease continues to grow, an in-depth review of this previously seldomly reported subtype of coronary ischemia was in order. Patients suffering coronary embolism are 15 to 20 years younger than traditional AMI patients with a slight predominance towards male sex, which resembles the gender data of the populations affected by non-traditional myocardial infarction in published reports. While the expected prevalence rate of cardiovascular disease risk factors such as hypertension and hyperlipidemia are present, this population also has a relatively high prevalence of atrial fibrillation and valve pathology, especially endocarditis. Initial presentation is indistinguishable from other causes of myocardial infarction however fever is commonly present, when endocarditis with valvular involvement is the primary cause of the coronary embolism. Mechanical thrombectomy is the mainstay of treatment, followed by percutaneous coronary intervention. Mortality is the highest in patients who do not receive targeted treatment for the coronary embolism, particularly if only antimicrobial agents or anticoagulation without thrombolytic agents are employed. The unique features of coronary embolism highlighted in this historical study justify further examination in contemporary patient populations.
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Lacey MJ, Raza S, Rehman H, Puri R, Bhatt DL, Kalra A. Coronary Embolism: A Systematic Review. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:367-374. [PMID: 31178350 DOI: 10.1016/j.carrev.2019.05.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/30/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Coronary embolism is a rare and potentially fatal phenomenon that occurs primarily in patients with valvular heart disease and atrial fibrillation. There is a lack of consensus regarding the diagnosis, treatment, and management of coronary embolism, leaving management at the discretion of the treating physician. Through this review, we aim to establish a better understanding of coronary embolism, and to identify treatment options - invasive and non-invasive - that may be used to manage coronary embolism. METHODS AND RESULTS Our systematic review included 147 documented cases of coronary embolism from case reports and case series. The average age of our population was 54.2 ± 17.6 years. The most common causes of coronary embolism included infective endocarditis (22.4%), atrial fibrillation (17.0%), and prosthetic heart valve thrombosis (16.3%). Initial presentation was indistinguishable from an acute coronary syndrome (ACS) due to coronary atherosclerosis, and the diagnosis required a high level of suspicion and evaluation with angiography. Treatment strategies included, but were not limited to, thrombectomy, thrombolysis, balloon angioplasty and stent placement. Myocardial dysfunction on echocardiography was observed in over 80% of patients following coronary embolism. "Good outcomes" were reported in 68.7% of case reports and case series, with a mortality rate of 12.9%. CONCLUSION Coronary embolism is an under-recognized etiology of myocardial infarction with the potential for significant morbidity and mortality. To improve outcomes, physicians should strive for early diagnosis and intervention based on the underlying etiology. Thrombectomy may be considered with the goal of rapid restoration of coronary flow.
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Affiliation(s)
- Matthew J Lacey
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Sajjad Raza
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Hasan Rehman
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, United States
| | - Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, United States
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, United States
| | - Ankur Kalra
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, United States.
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Acute inferior ST-segment elevation myocardial infarction and previous cryptogenic stroke caused by a paradoxical embolism with a concomitant pulmonary embolism. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2017; 14:421-424. [PMID: 29056952 PMCID: PMC5540877 DOI: 10.11909/j.issn.1671-5411.2017.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Omar HR. ST-segment elevation in V1-V4 in acute pulmonary embolism: a case presentation and review of literature. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 5:579-586. [PMID: 26373811 DOI: 10.1177/2048872615604273] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 08/14/2015] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Electrocardiographic (ECG) abnormalities are seen in 70%-80% of patients with acute pulmonary embolism (APE). Rarely, APE presents with ST-segment elevation (STE) in leads V1-V4, mimicking ST-segment elevation myocardial infarction (STEMI). Herein, we describe a case of APE presenting with STE in V1-V3, along with a comprehensive review of the literature. METHODS We reviewed Pubmed/Medline indexed articles from 1950 to 2014 reporting cases of APE presenting with STE in V1-V3 or V4 (V1-V3/V4). Cases were analyzed with specific reference to patient demographics, clinical, laboratory, and radiological data, treatment, and outcome. RESULTS A total of 12 cases were identified comprising seven males and five females aged between 31 and 64 years. Five cases met the American College of Cardiology/American Heart Association criteria for massive APE due to sustained hemodynamic instability or requirement for inotropic support, and seven met criteria for submassive PE due to right ventricular (RV) dysfunction or elevated troponin in absence of systemic hypotension. Among the notable clinical features in this cohort is the high incidence of syncope, in 66.7% of the cases, high incidence of concomitant deep venous thrombosis (DVT) in 90% of cases that reported venous Doppler results (eight proximal and one distal DVT), and the presence of a dilated RV in 90% of the cases that reported echocardiographic results. In all but one case the initial working diagnosis was STEMI and emergent cardiac catheterization was planned. In the 90% of cases who eventually had a coronary angiography, the angiogram was performed prior to diagnosing APE, and the lack of occlusive disease prompted further workup that confirmed the diagnosis of APE. In-hospital mortality rate in the studied population was 16.7%. CONCLUSION STE in leads V1-V3/V4 in cases with APE identifies a subset of patients who are an intermediate to high risk category. In cases presenting with right precordial lead STE and clinical features that are more suggestive of APE rather than STEMI, a computed tomography pulmonary angiogram is warranted for earlier diagnosis of suspected APE, which allow for immediate-rather than delayed-initiation of therapeutic anticoagulant therapy if the diagnosis is confirmed and may avert the need for coronary angiography.
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Affiliation(s)
- Hesham R Omar
- Internal Medicine Department, Mercy Medical Center, USA
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[Acute myocardial infarction due to a coronary embolism and a massive pulmonary thromboembolism in a young patient. A difficult to manage combination]. Semergen 2014; 41:e67-9. [PMID: 25440974 DOI: 10.1016/j.semerg.2014.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 07/28/2014] [Accepted: 08/02/2014] [Indexed: 11/20/2022]
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Tukaye DN, Cavallazzi RS. Paradoxical Thromboembolism/ST-Elevation Myocardial Infarction via a Patent Foramen Ovale in Sub-Massive Pulmonary Embolism Following an Upper Extremity Deep Venous Thrombosis: Is It Time for a Change in the Standard of Care? Cardiol Res 2014; 5:112-117. [PMID: 28348707 PMCID: PMC5358172 DOI: 10.14740/cr335w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2014] [Indexed: 11/11/2022] Open
Abstract
The objective of this case study is to discuss a rare case of proven paradoxical thromboembolism captured in-transit. A 23-year-old female with a diagnosis of right internal jugular deep vein thrombus who developed acute onset chest pain, dyspnea and hypotension, was selected for the study. Sub-massive PE and STEMI were diagnosed. Transthoracic echocardiogram revealed a left ventricular (LV) mass moving across the aortic valve. Soon after, the patient developed numbness of right extremities with non-palpable pulses. A transesophageal echocardiogram revealed absent LV mass, PFO, left atrial mass entering through the PFO and emboli in bilateral pulmonary arteries. We report a case of sub-massive PE and paradoxical proven coronary and upper extremity embolism, captured in-transit, following destabilization of an UEDVT in a patient with PFO.
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Affiliation(s)
| | - Rodrigo Silva Cavallazzi
- Division of Medicine Pulmonary Critical Care, University of Louisville, Louisville, KY 40202, USA
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Smith JG, Koul S, Roijer A, Holmqvist J, Keussen I, Cwikiel W, Ohlin B, Erlinge D. Acute right ventricular failure caused by concomitant coronary and pulmonary embolism: successful treatment with endovascular coronary and pulmonary thrombectomy. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 2:131-6. [PMID: 24222822 DOI: 10.1177/2048872613486336] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 03/24/2013] [Indexed: 12/15/2022]
Abstract
Patent foramen ovale (PFO) is present in approximately 25% of the general population. PFO is characterized by intermittent shunting of blood from the right to the left atrium, especially in the context of increased right-sided filling pressures, with risk of paradoxical embolism. We describe a 69-year-old woman presenting with acute chest pain, severe dyspnoea, and acute inferolateral ST-segment elevation on the electrocardiogram. The patient was diagnosed with myocardial infarction and failure of the right cardiac ventricle, which was considered to be secondary to extensive pulmonary embolism leading to increased filling pressures and paradoxical coronary embolism. The patient underwent emergent percutaneous interventions with coronary thrombus extraction and pulmonary thrombus fragmentation and local thrombolysis. The patient was free of symptoms at follow up 6 months later and echocardiography showed substantially improved right ventricular function. We discuss issues related to the diagnosis, treatment, and secondary prevention for patients with concomitant pulmonary and coronary arterial thrombosis.
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Affiliation(s)
- J Gustav Smith
- Lund University, Lund, Sweden ; Skåne University Hospital, Lund, Sweden
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Zhan ZQ, Wang CQ, Nikus KC, He CR, Wang J, Mao S, Dong XJ. Electrocardiogram patterns during hemodynamic instability in patients with acute pulmonary embolism. Ann Noninvasive Electrocardiol 2014; 19:543-51. [PMID: 24750207 DOI: 10.1111/anec.12163] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND We have previously described new electrocardiogram (ECG) findings for massive pulmonary embolism, namely ST-segment elevation in lead aVR with ST-segment depression in leads I and V4 -V6 . However, the ECG patterns of patients with acute pulmonary embolism during hemodynamic instability are not fully described. METHODS We compared the differences between the ECG at baseline and after deterioration during hemodynamic instability in twenty patients with acute pulmonary embolism. RESULTS Compared with the ECG at baseline, three ischemic ECG patterns were found during clinical deterioration with hemodynamic instability: ST-segment elevation in lead aVR with concomitant ST-segment depression in leads I and V4 -V6 , ST-segment elevation in leads V1 -V3 /V4 , and ST-segment elevation in leads III and/or V1 /V2 with concomitant ST-segment depression in leads V4 /V5 -V6 . Ischemic ECG patterns with concomitant S1Q3 and/or abnormal QRS morphology in lead V1 were more common (90%) during hemodynamic instability than at baseline (5%) (P = 0.001). CONCLUSIONS Hemodynamic instability in acute pulmonary embolism is reflected by signs of myocardial ischemia combined with the right ventricular strain pattern in the 12-lead ECG.
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Affiliation(s)
- Zhong-qun Zhan
- Department of Cardiology, Shiyan Taihe Hospital, Hubei University of Medicine, Shiyan City, Hubei Province, China
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Udayakumaran K, Subban V, Pakshirajan B, Lakshmanan A, Kalidoss L, Rajaram RS, Janakiraman E, Mullasari S A. Primary percutaneous thrombus aspiration alone as definitive intervention for left main coronary artery occlusion presenting as acute anterior wall ST elevation myocardial infarction. Heart Lung Circ 2013; 23:166-70. [PMID: 23973559 DOI: 10.1016/j.hlc.2013.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 07/09/2013] [Accepted: 07/24/2013] [Indexed: 10/26/2022]
Abstract
Primary angioplasty and stenting remains the standard of care for patients presenting with acute ST-segment elevation myocardial infarction. Recently, thrombus aspiration has been shown to improve the myocardial perfusion and outcomes in STEMI. In a subset of patients thrombus aspiration may result in optimal perfusion and minimal residual stenosis. These patients may be managed without additional stenting. Three patients with anterior wall STEMI were successfully managed with thrombus aspiration alone without additional stenting. All three are doing well at 30 day follow up with significant improvement in left ventricular ejection fraction.
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Affiliation(s)
- Kalaichelvan Udayakumaran
- Department of Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India.
| | - Vijayakumar Subban
- Department of Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India
| | - Balaji Pakshirajan
- Department of Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India
| | - Anitha Lakshmanan
- Department of Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India
| | - Latchumanadhas Kalidoss
- Department of Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India
| | - Ramkumar Soli Rajaram
- Department of Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India
| | - Ezhilan Janakiraman
- Department of Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India
| | - Ajit Mullasari S
- Department of Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India
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Kramer MC, Verouden NC, Li X, Koch KT, van der Wal AC, Tijssen JG, de Winter RJ. Thrombus aspiration alone during primary percutanous coronary intervention as definitive treatment in acute ST-elevation myocardial infarction. Catheter Cardiovasc Interv 2012; 79:860-7. [PMID: 21735523 DOI: 10.1002/ccd.23214] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 03/26/2011] [Indexed: 01/12/2023]
Affiliation(s)
- Miranda C Kramer
- Department of Cardiology, Academic Medical Center, University of Amsterdam, The Netherlands
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Wöhrle J, Kochs M, Hombach V, Merkle N. Prevalence of myocardial scar in patients with cryptogenic cerebral ischemic events and patent foramen ovale. JACC Cardiovasc Imaging 2010; 3:833-9. [PMID: 20705263 DOI: 10.1016/j.jcmg.2010.05.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 03/29/2010] [Accepted: 05/03/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES This study sought to evaluate the prevalence of subclinical myocardial infarctions with cardiovascular magnetic resonance imaging (CMRI) in patients with patent foramen ovale (PFO) after cryptogenic cerebral ischemic events. BACKGROUND A thrombotic mass passing a PFO may embolize in cerebral but also in coronary arteries, resulting in both cerebral and myocardial ischemic events. CMRI with late gadolinium enhancement (LGE) analysis is the most sensitive imaging technique to detect small myocardial infarctions. METHODS PFO patients (n = 74) with a first cryptogenic cerebral ischemic event without a clinical history for myocardial infarction underwent CMRI and coronary angiography. Right and left ventricular volumes and ejection fractions were measured by CMRI. LGE imaging was performed after administration of gadolinium-diethylenetriaminepentaacetic acid. The presence of atrial septal aneurysm (ASA) was evaluated by transesophageal echocardiography. RESULTS LGE was detected in 8 of 74 (10.8%) patients. LGE pattern was transmural or subendocardial. Patients with LGE and those without did not differ in cardiovascular risk factors, type of ischemic event, presence of ASA, right and left ventricular volumes, and ejection fractions. LGE volume was small and comprised only 7.9 +/- 2.4% of left ventricular muscle mass. Coronary artery disease was ruled out in 7 of 8 patients with LGE. There was a trend towards a larger PFO size in patients with LGE compared with patients without LGE (13.2 +/- 4.1 mm vs. 16.0 +/- 2.8 mm, p = 0.06). CONCLUSIONS Subclinical myocardial infarctions determined in CMRI were observed in 10.8% of patients with PFO after a first cryptogenic cerebral ischemic event. Our results strengthen the pathophysiologic role of a PFO with paradoxical embolism in patients with cryptogenic cerebral ischemic events.
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Affiliation(s)
- Jochen Wöhrle
- Clinic of Internal Medicine II, University of Ulm, Ulm, Germany.
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