Multivessel coronary thrombosis secondary to cocaine use successfully treated with multivessel primary angioplasty

Simultaneous total occlusion of the 3 major coronary arteries in a patient with inferior ST-segment elevation myocardial infarction complicated by cardiogenic shock and sinus bradycardia

Simultaneous occlusion of more than one coronary artery is uncommon and associated with poor prognosis. We reported a particular case of a 62-year-old patient, who presented with an inferior ST-segment elevation myocardial infarction with right ventricular involvement complicated by cardiogenic shock, sinus bradycardia, and an extensive echocardiographic ischemia with severe left ventricular systolic dysfunction. Coronary angiography revealed occlusion of 3 major coronary arteries. Primary percutaneous coronary intervention of the right coronary artery was performed with hemodynamic recovery, chest pain, and ST-segment resolution. Treatment for heart failure with reduced ejection fraction was initiated, with a good outcome.

A Multimodal Framework for Improving in Silico Drug Repositioning With the Prior Knowledge From Knowledge Graphs

Drug repositioning/repurposing is a very important approach towards identifying novel treatments for diseases in drug discovery. Recently, large-scale biological datasets are increasingly available for pharmaceutical research and promote the development of drug repositioning, but efficiently utilizing these datasets remains challenging. In this paper, we develop a novel multimodal framework, termed GraphPK (Graph-based Prior Knowledge) for improving in silico drug repositioning via using the prior knowledge from a drug knowledge graph. First, we construct a knowledge graph by integrating relevant bio-entities (drugs, diseases, etc.) and associations/interactions among them, and apply the knowledge graph embedding technique to extract prior knowledge of drugs and diseases. Moreover, we make use of the known drug-disease association, and obtain known association-based features from an association bipartite graph through graph embedding, and also take into account biological domain features, i.e., drug chemical structures and disease semantic similarity. Finally, we design a multimodal neural network to combine three types of features from the knowledge graph, the known associations and the biological domain, and build the prediction model for predicting drug-disease associations. Massive experiments show that our method outperforms other state-of-the-art methods in terms of most metrics, and the ablation analysis regarding the three types of features reveals that prior knowledge from knowledge graphs can not only lift the predictive power of in silico drug repositioning, but also enhance the model's robustness to different scenarios. The results of case studies offer support that GraphPK has the potential for actual use.

Acute myocardial infarction with simultaneous total occlusion of the left anterior descending artery and right coronary artery successfully treated with percutaneous coronary intervention

BACKGROUND

Simultaneous thrombosis in more than one coronary artery is an uncommon angiographic finding in patients with acute ST-segment elevation myocardial infarction. It is difficult to identify using 12-lead electrocardiography and usually leads to cardiogenic shock and fatal outcomes, including sudden cardiac death. Therefore, immediate revascularization and adequate mechanical circulatory support are required.

CASE PRESENTATION

We report the case of a 58-year-old man who presented with vomiting and chest pain complicated by cardiogenic shock and complete atrioventricular block. Electrocardiography revealed ST-segment elevation in leads II, III, aVF, and V1-V6. Emergency coronary angiography revealed total occlusion of the proximal left anterior descending artery and right coronary artery. The patient successfully underwent primary percutaneous coronary intervention with ballooning and stenting for both arteries. An Impella CP was inserted during the procedure. Fifty-seven days after admission, he had New York Heart Association class II heart failure and was transferred to a rehabilitation hospital.

CONCLUSIONS

Acute double-vessel coronary thrombosis, a serious event with a high mortality rate, requires prompt diagnosis and management to prevent complications such as cardiogenic shock and ventricular arrhythmias. A combination of judicious medical treatment, efficient primary percutaneous coronary intervention, and early mechanical support device insertion is crucial to improve the survival rate of patients with this disease.

Acute double coronary occlusion and its misleading presentation: An unusual case report

Acute simultaneous double coronary occlusion is an extremely rare condition with an unspecific presentation.

We report a case of a 57-year-old male, with undiagnosed diabetes mellitus, presenting with acute epigastralgia and vomiting associated with dynamic electrocardiographic changes. He was hemodynamically stable. Emergency coronary angiogram showed a total occlusion of both proximal left circumflex and mid left anterior descending coronary artery. Since the EKG indicated minimal ST-segment elevation in the lateral leads as well as an ST depression in the inferior leads, we performed a percutaneous coronary intervention of both the LCx and LAD, using a floppy guidewire.

Similar cases of multiple simultaneous coronary occlusions are reported in literature, yet the accurate incidence and physiopathology of this occurrence is still uncertain.

Although this condition is associated with serious complications, our case evolved favorably due to prompt management.

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Acute coronary syndromes are a major cause of cardiovascular mortality.

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Simultaneous acute double coronary occlusion is a rare condition.

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Its presentation is often misleading.

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Complications are frequent and fatal.

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Mortality may be avoided by an early diagnosis and invasive management.

Simultaneous coronary thrombosis with multisite myocardial infarction and complex malignant arrhythmia: A case report

INTRODUCTION

Acute myocardial infarction with simultaneous coronary thrombosis has been rarely reported. This combination induces various arrhythmias and is a high-risk factor for cardiogenic shock.

PATIENT CONCERNS

A 65-year-old man presented with sweating and a 3-h abrupt persistent back pain that radiated to the anterior.

DIAGNOSIS

Multisite myocardial infarction, coronary thrombosis with and complex malignant arrhythmia INTERVENTIONS:: Prompt intervention includes cardiac pacing, percutaneous coronary intervention (PCI), thrombus aspiration and intra-aortic balloon pump (IABP).

OUTCOMES

The patient was successfully rescued after PCI and thrombus aspiration.

CONCLUSIONS

Recognition of dynamic electrocardiographic changes enhances our understanding of the pathogenesis of myocardial infarction.

A Successfully Treated STEMI Due to Simultaneous Thrombotic Occlusion of Left Anterior Descending Artery and Left Circumflex Artery: A Case Report and Review of the Literature

ST-segment elevation myocardial infarction (STEMI) due to simultaneous double vessel thrombotic occlusion of two major coronary arteries is an extremely rare clinical entity. Available studies indicate that most frequently it affects two coronary arteries originating from different sides of a coronary tree (i.e. right coronary artery (RCA) and left anterior descending artery (LAD) or RCA and left circumflex artery (LCx)) and usually has a fatal clinical course. However, it must be pointed out that the data have been derived from studies before the era of a widely-used pre-hospital electrocardiogram (ECG) teletransmission. Herein, we present a case report of successfully-treated STEMI due to simultaneous occlusion of LAD and LCx. Furhtermore, the case report highlights a crucial role of ECG teletransmission for immediate treatment and survival of patients with the so-called “the deadly double infarct syndrome”.

Multiple Culprit Coronary Artery Thrombosis in a Patient with Coronary Ectasia

We here report a case of ST-elevation myocardial infarction (STEMI) due to simultaneous acute coronary artery occlusions of two major coronary arteries in a patient with coronary ectasia. The patient had been previously submitted to percutaneous coronary angioplasty with bare metal stent implantation in both culprit vessels. Very late stent thrombosis could be the cause of the first occlusion, triggering the event in the other vessel. In addition, concomitant embolic sources were not identified. Although routine aspiration thrombectomy in STEMI was not proven to be beneficial in randomized clinical trials, it was of great value in this case. We also discuss the relation between coronary ectasia, chronic inflammatory status, and increased platelet activity which may have caused plaque disruption in another already vulnerable vessel.

Summation and Cancellation Effects on QRS and ST-Segment Changes Induced by Simultaneous Regional Myocardial Ischemia

Simultaneous ischemia in two myocardial regions is a potentially lethal clinical condition often unrecognized whose corresponding electrocardiographic (ECG) patterns have not yet been characterized. Thus, this study aimed to determine the QRS complex and ST-segment changes induced by concurrent ischemia in different myocardial regions elicited by combined double occlusion of the three main coronary arteries. For this purpose, 12 swine were randomized to combination of 5-min single and double coronary artery occlusion: Group 1: left Circumflex (LCX) and right (RCA) coronary arteries (n = 4); Group 2: left anterior descending artery (LAD) and LCX (n = 4) and; Group 3: LAD and RCA (n = 4). QRS duration and ST-segment displacement were measured in 15-lead ECG. As compared with single occlusion, double LCX+RCA blockade induced significant QRS widening of about 40 ms in nearly all ECG leads and magnification of the ST-segment depression in leads V1-V3 (maximal 228% in lead V3, p < 0.05). In contrast, LAD+LCX or LAD+RCA did not induce significant QRS widening and markedly attenuated the ST-segment elevation in precordial leads (maximal attenuation of 60% in lead V3 in LAD+LCX and 86% in lead V5 in LAD+RCA, p < 0.05). ST-segment elevation in leads V7-V9 was a specific sign of single LCX occlusion. In conclusion, concurrent infero-lateral ischemia was associated with a marked summation effect of the ECG changes previously elicited by each single ischemic region. By contrast, a cancellation effect on ST-segment changes with no QRS widening was observed when the left anterior descending artery was involved.

Acute myocardial infarction with multiple coronary thromboses in a young addict of amphetamines and benzodiazepines

A 35-year-old man of average build and a smoker, with a background of a psychiatric disorder, was brought by his neighbor to the emergency department after an hour of severe chest pain. Upon arrival at the hospital he had cardiac arrest, was resuscitated, and moved to the catheterization laboratory with inferior, posterior, and lateral myocardial infarction. Coronary angiography showed an unusual thrombosis in multiple coronary branches. Toxicology report showed high levels of amphetamines and benzodiazepines in the patient's original blood sample. The patient was kept under ventilation for 18 days, with difficult recovery due to severe withdrawal manifestations, ventilation acquired pneumonia, and rhabdomyolysis inducing acute renal failure. The patient regained near normal left ventricular function after baseline severe regional and global dysfunction. We postulate a relationship between the use of amphetamines, potentiated by benzodiazepines, and occurrence of acute thrombosis of multiple major coronary arteries.

Simultaneous thrombosis of the left anterior descending artery and the right coronary artery in a 34-year-old crystal methamphetamine abuser

This case report underscores that crystal methamphetamine abuse is an important cause of multivessel coronary thrombosis and raises doubts about the therapeutic options. The patient was a 34-year-old smoker and crystal methamphetamine abuser with no significant medical history, who presented with retrosternal chest pain associated with cold sweats. Twelve-lead electrocardiogram revealed diffuse ST-segment elevation in I, II, AVL, AVF, and V 2-6 leads. He underwent urgent coronary angiography and it showed Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow in coronary arteries and presence of a thrombus in the left anterior descending artery (LAD) and the right coronary artery (RCA). The patient underwent medical therapy with antiplatelet agents and anticoagulants. Repeat coronary angiography after three months of dual therapy with warfarin and aspirin did not show any thrombus or any significant lesion in the RCA and the LAD having TIMI grade 3 flow.

Simultaneous double coronary thrombosis in a 47-year-old male patient with acute myocardial infarction

PATIENT

Male, 47 FINAL DIAGNOSIS: Acute myocardial infarction Symptoms: Chest pain Medication: - Clinical Procedure: - Specialty: Cardiology.

OBJECTIVE

Unusual clinical course.

BACKGROUND

Double myocardial infarction involving two culprit major vessels is a rarely reported presentation with high incidence of mortality.

CASE REPORT

In this study, we report 47-year-old male patient who had an attack of chest pain associated with ST-segment elevation in the antero-lateral leads. Pharmaco-invasive reperfusion approach was adopted with full dose tissue plasminogen activator, followed by transferring the patient to a specialized heart center for Percutaneous Coronary Intervention (PCI). Coronary angiography showed a fresh thrombus totally occluding Left Anterior Descending (LAD) and another thrombus causing distal total occlusion of a dominant Right Coronary Artery (RCA). Two Bare metal stents were placed in both lesions with Thrombolysis in Myocardial Infarction (TIMI) 3 flow post dilatation, but the patient, unfortunately, went into Ventricular Fibrillation (VF) followed by asystole and died 35 minutes later.

CONCLUSIONS

Acute double vessel coronary artery thrombosis is a serious event that requires prompt diagnosis and management to prevent its complications.

Cocaine-induced coronary thrombosis: what is the optimal treatment strategy

Arterial thrombosis and especially coronary thrombosis are known complications of cocaine abuse. We report three cases of severe life-threatening coronary arterial thrombosis manifesting as acute coronary syndromes. Thrombosis occurred predominantly in the proximal coronary tree with spontaneous distal embolization. The thrombotic occlusions were frequently not superimposed on flow-limiting atherosclerotic lesions. Treatment of these patients with thrombolytic, antithrombotic and anti-platelet therapy resulted in thrombus and symptom resolution. While stenting these vessels can be successfully executed and may be required in some cases of ST-elevation myocardial infarction, it may expose these patients to the risk of stent thrombosis, which is reported to be significantly higher than the risk of the general population.

Outcomes of coronary artery bypass grafting in patients with a history of opiate use

This study aimed at evaluating the outcome of CABG in patients with a history of opiate use. Two hundred male patients, underwent CABG surgery, were evaluated and followed up for 6 months. The patients classified as Group P (with Previous history of opiate use) and Group N (with No history of opiate use). The characteristics and 6-month outcomes were compared between the two groups. Patients in group P further categorized into two subgroups of active and non-active abusers. Two hundred male-patients enrolled in the study, 23 (11.5%) patients had a history of opiate abuse. Nine (4.5%) patients were past users and 14 (7%) cases were current users. There were no significant differences regarding the age, history of hypertension, smoking, ejection fraction before and 6 months after CABG, duration of hospital stay, complications of surgery and function class (p<0.05). The level of patients obeys from physician's medical, nutritional and activity recommendations after CABG was significantly lower for current opiate users. Also, the need for readmission after CABG due to cardiac complications was independently higher in current opiate users. Carrying out the educational programs to correct the misconception about the beneficial effects of illicit drugs on cardio-vascular disease makes sense.

Management of cocaine-induced cardiac arrhythmias due to cardiac ion channel dysfunction

Cocaine use is common in many areas of the world, particularly the United States and Western Europe. Toxicity following the use of cocaine is associated with a wide range of clinical features. In this review, we will focus on the cocaine-associated cardiac arrhythmias and, in particular, some of the controversies in their etiology and management. Cocaine can produce arrhythmias either through the production of myocardial ischemia or as a direct result of ion channel alterations. Excessive catecholamines, combined with sodium and potassium channel blockades, give rise to a wide variety of supra-ventricular and ventricular rhythms. The animal and human evidence for ion channel dysfunction is reviewed, and the effects of catecholamines are followed from the cardiac action potential to the development of arrhythmias. Finally, theoretical constructs are combined with existing evidence to develop a rational treatment strategy for patients with cocaine-induced cardiac arrhythmias. In particular, we review the evidence concerning the controversies relating to the use of lidocaine in comparison with sodium bicarbonate, in terms of QRS prolongation secondary to sodium channel blockade.

Increased incidence of stent thrombosis in patients with cocaine use

INTRODUCTION

Coronary stent thrombosis is a rare occurrence in the era of dual-antiplatelet therapy. It is not known whether patients who use cocaine have a higher risk of thrombosis following coronary stent placement.

METHODS

We studied 247 consecutive patients who underwent coronary stent placement at an inner-city hospital.

RESULTS

Twelve patients (4.9%) were actively using cocaine at the time of PCI. Of these twelve patients, four patients presented with stent thrombosis (33%) at a mean of 51 +/- 40 days (median 45 days), after the index revascularization procedure. Only 2 of the 235 patients without documented cocaine use (0.85%) had stent thrombosis during the same period (P < 0.0001).

CONCLUSION

The patients who actively use cocaine have a markedly higher risk of stent thrombosis when compared with patients without a documented history of cocaine use. We discuss various factors that potentially predispose cocaine users to stent thrombosis.