Myocardial infarction with normal coronary arteries after acute exposure to carbon monoxide

Practical Recommendations for the Evaluation and Management of Cardiac Injury Due to Carbon Monoxide Poisoning

Carbon monoxide (CO) is a relatively frequent cause of poisoning evaluated in emergency departments. The risk of neurologic injuries, such as cognitive, psychological, vestibular, and motor deficits, is 25% to 50%. However, the risk of cardiac injuries should also be considered. Among patients with CO poisoning, the mortality in patients with myocardial injury is approximately 3 times greater than that in patients without myocardial injury. In large-scale studies, up to 69.2% of patients with acute CO poisoning exhibiting elevated troponin I levels and no underlying cardiovascular illnesses had late gadolinium enhancement on cardiac magnetic resonance, suggesting covert CO-induced myocardial fibrosis. Myocardial damage can be evaluated using electrocardiography, echocardiography, computed tomography, and cardiac magnetic resonance. This paper offers recommendations for cardiac evaluations based on our collective experience of managing >2,000 cases of acute CO poisoning with supporting information taken from peer-reviewed published reports on CO poisoning.

The Relationship between Fragmented QRS and Myocardial Injury in Patients with Acute Carbon Monoxide Poisoning

Background and Objectives: Carbon monoxide (CO) intoxication is one of the most common causes of poisoning-related deaths and complications. Myocardial injury is an important complication of CO poisoning. In our study, we aimed to evaluate the relationship between the presence and prevalence of fragmented QRS (fQRS) and myocardial injury in patients with CO intoxication. Materials and Methods: We retrospectively evaluated patients who presented to the emergency department of our tertiary care center with CO intoxication between January 2020 and December 2023. In our study, we performed subgroup analyses according to the presence of myocardial injury and fQRS. We evaluated the parameters and risk factors associated with myocardial injury. Results: Myocardial injury was detected in 44 patients, and fQRS was detected in 38 patients. In the myocardial injury (+) group, the fQRS rate was 38.6%, and the median number of leads with fQRS was 3 (2-6) and was significantly higher than in the myocardial injury (-) group (p < 0.001). We found that carboxyhemoglobin had a significant positive correlation with troponin (p = 0.001) and pro-B-type natriuretic peptide (proBNP) (p = 0.009). As a result of multivariate analysis, we determined that age, creatinine, proBNP, fQRS, and ≥3 leads with fQRS are independent risk factors for myocardial injury. Conclusions: Myocardial injury in CO intoxication patients is associated with proBNP, the presence of fQRS, and the number of leads with fQRS. Age, creatinine level, proBNP, the presence of fQRS, and ≥3 leads with fQRS are independent risk factors for myocardial injury in patients with CO intoxication.

Clinical and Laboratory Characteristics Predicting the Severity of Carbon Monoxide Poisoning in Children: A Single-Center Retrospective Study

OBJECTIVES

Carbon monoxide poisoning (COP) is extremely common throughout the world. The purpose of this study was to assess the demographic, clinical, and laboratory characteristics predicting the severity COP in children.

METHODS

The study included 380 children diagnosed with COP between January 2017 and January 2021 and 380 healthy controls. Carbon monoxide poisoning was diagnosed based on the medical history and a carboxyhemoglobin (COHb) level of more than 5%. The patients were classified as mild (COHb 10%), moderate (COHb 10%-25%), or severely (COHb > 25%) poisoned.

RESULTS

The mean age of the severe group was 8.60 ± 6.30, for the moderate group was 9.50 ± 5.81, for the mild group was 8.79 ± 5.94, and for the control group was 8.95 ± 5.98. The most common place of exposure was at home and all cases were affected accidentally. The coal stove was the most common source of exposure, followed by natural gas. The most common symptoms were nausea/vomiting, vertigo, and headache. Neurologic symptoms such as syncope, confusion, dyspnea, and seizures were more common in the severe group. A total of 91.3% of the children had hyperbaric oxygen therapy, 3.8% were intubated, and 3.8% were transferred to intensive care in the severe group, whereas no death or sequela was observed. Mean platelet volume and red cell distribution width had the highest area under the curve in the receiver operating characteristic analysis (0.659; 0.379). A positive and low statistically significant relationship was found between COHb levels and troponin and lactate levels in the severe group ( P < 0.05).

CONCLUSIONS

Carbon monoxide poisoning progressed more severely in children presented with neurological symptoms and have elevated red cell distribution width and mean platelet volume. Even in severe COP cases, satisfactory results have been obtained with early and appropriate treatment.

Effect of early intervention on short-term prognosis of patients with myocardial injury induced by acute carbon monoxide poisoning

AIM

This study aimed to investigate the effect of early intervention on the short-term prognosis of patients with myocardial injury induced by acute carbon monoxide poisoning (ACOP).

METHODS AND RESULTS

We performed a retrospective cohort study of 139 patients admitted to the hospital for ACOP-induced acute toxic cardiopathy. Compared with the mild and moderate toxic cardiopathy group, the severe toxic cardiopathy group has significantly increased coma time, acute physiology and chronic health status (APACHE) II score, and the length of hospital stay and significantly reduced proportion of patients with immediate endotracheal intubation and early admission to intensive care unit (ICU) (all P < 0.05). The cardiac troponin I (cTnI) levels and corrected QT dispersion (QTcd) duration in three patient groups were significantly higher (all P < 0.05) than those in the control group, with the highest in the severely toxic heart disease group. Serum cTnI level and QTcd duration were two independent predictors of myocardial injury in ACOP patients. There was a positive correlation between the APACHE II score and serum cTnI level/QTcd duration at admission. The sensitivities of cTnI and QTcd at admission to diagnose serious cardiovascular events were 78.6% and 85.7%, respectively, and the specificities were both 75%.

CONCLUSIONS

Acute carbon monoxide poisoning patients with myocardial injury need to be admitted to the hospital as early as possible. For patients with severe hypoxia, an artificial airway should be established as early as possible, and patients should be admitted to the monitoring ward to stabilize their condition at the early stage of poisoning. Meanwhile, changes in QTcd, serum cTnI, and creatine kinase-MB (CK-MB) should be closely observed.

Frontal QRS-T angle as a predictive marker for myocardial damage in acute carbon monoxide poisoning

INTRODUCTION

The present study was undertaken to investigate the prognostic value of the frontal QRS-T angle associated with adverse cardiac outcomes in patients with carbon monoxide (CO) poisoning in early stages in the emergency department.

MATERIALS AND METHODS

The data of 212 patients with CO poisoning who were admitted to the ED between January 2010 and May 2020 were retrospectively analyzed. The frontal QRS-T angle was obtained from the automatic reports of the EKG device.

RESULTS

Compared to patients without myocardial damage, among patients with myocardial damage, statistically high creatinine, creatine kinase MB, cardiac troponin I, and frontal QRS-T angle values were found (p < 0.001 for all parameters), while the saturation of arterial blood pH and arterial oxygen values were found to be lower (p = 0.002 and p < 0.001, respectively). The frontal QRS-T angle values were correlated with creatine kinase, creatine kinase-MB, cardiac troponin I, and oxygen saturation (SpO₂) in arterial blood (r = 0. 232, p = 0.001; r = 0. 253, p = < 0.001; r = 0. 389, p = < 0.001; r = -0. 198, p = 0.004, respectively). The optimum cut-off value of the frontal QRS-T angle was found to be 44.5 (area under the curve: 0.901, 95% confidence interval: 0.814-0.988, sensitivity: 87%, specificity: 84%).

CONCLUSIONS

The frontal QRS-T angle, a simple and inexpensive parameter that can be easily obtained from 12-lead surface electrocardiography, can be used as an early indicator in the detection of myocardial damage in patients with CO poisoning.

The Value of Neutrophil:Lymphocyte Ratio and Platelet:Lymphocyte Ratio in Predicting Clinical Severity in Children with Carbon Monoxide Poisoning

OBJECTIVE

To compare the values of neutrophil:lymphocyte ratio (NLR), platelet:lymphocyte ratio (PLR), and mean platelet volume (MPV) with carboxyhemoglobin (COHb) and lactate levels in children with acute CO intoxication.

METHODS

In this retrospective study, the patients were divided into two groups: mild-to-moderate carbon monoxide poisoning (COP) (COHb 10%-20%) and severe COP (COHb > 20%) according to the COHb levels in the application. All patients were compared in terms of NLR, PLR, and MPV parameters according to the severity of poisoning and the high lactate levels (≥ 2.2 mmol/L).

RESULTS

A total of 261 children with COP were included in the study. The number of patients with mild-to-moderate COP was 183 (70.1%), and the number of patients with severe COP was 78 (29.9%). NLR [2.57 (3.27), 1.65 (1.93), (p = 0.001)] and PLR [123.0 (88.24), 92.8 (54.1), (p = 0.001)] values of mild-to-moderate COP were statistically significantly lower than the severe COP group. In the group with high lactate level, PLR values were significantly lower [120.1 (71.9), 100.2 (85.4), (p = 0.017)]. NLR and PLR values were found to be predictive of severe COP.

CONCLUSION

NLR and PLR can be used for detection of clinical severity in patients with COP. PLR can be used in conjunction with lactate levels to detect tissue-level exposure in patients with COP.

Air pollutants and outpatient visits for cardiovascular disease in a severe haze-fog city: Shijiazhuang, China

Background

Many studies have reported the impact of air pollution on cardiovascular disease (CVD), but few of these studies were conducted in severe haze-fog areas. The present study focuses on the impact of different air pollutant concentrations on daily CVD outpatient visits in a severe haze-fog city.

Methods

Data regarding daily air pollutants and outpatient visits for CVD in 2013 were collected, and the association between six pollutants and CVD outpatient visits was explored using the least squares mean (LSmeans) and logistic regression. Adjustments were made for days of the week, months, air temperature and relative humidity.

Results

The daily CVD outpatient visits for particulate matter (PM₁₀ and PM_2.5), sulphur dioxide (SO₂), nitrogen dioxide (NO₂), carbon monoxide (CO), and ozone (O₃) in the 90th-quantile group were increased by 30.01, 29.42, 17.68, 14.98, 29.34%, and − 19.87%, respectively, compared to those in the <10th-quantile group. Odds ratios (ORs) and 95% confidence intervals (CIs) for the increase in daily CVD outpatient visits in PM₁₀ 300- and 500-μg/m³, PM_2.5 100- and 300-μg/m³ and CO 3-mg/m³ groups were 2.538 (1.070–6.020), 7.781 (1.681–36.024), 3.298 (1.559–6.976), 8.72 (1.523–49.934), and 5.808 (1.016–33.217), respectively, and their corresponding attributable risk percentages (AR%) were 60.6, 87.15, 69.68, 88.53 and 82.78%, respectively. The strongest associations for PM₁₀, PM_2.5 and CO were found only in lag 0 and lag 1. The ORs for the increase in CVD outpatient visits per increase in different units of the six pollutants were also analysed.

Conclusions

All five air pollutants except O₃ were positively associated with the increase in daily CVD outpatient visits in lag 0. The high concentrations of PM₁₀, PM_2.5 and CO heightened not only the percentage but also the risk of increased daily CVD outpatient visits. PM₁₀, PM_2.5 and CO may be the main factors of CVD outpatient visits.

Predicting of neuropsychosis in carbon monoxide poisoning according to the plasma troponin, COHb, RDW and MPV levels: Neuropsychoses in carbon monoxide poisoning

OBJECTIVE

Carbon monoxide (CO) poisoning is very common worldwide. In this study, we aimed to evaluate the predictivity of neuro psychosis in carbon monoxide poisoning by the admission levels of red cell distribution (RDW), mean platelet volume (MPV) and troponin I levels which can be measured quickly and easily in the emergency department (ED).

PATIENTS AND METHODS

This single center observational study included a total of 216 consecutive patients who presented to the ED due to CO poisoning between January 2009 and December 2013. The diagnosis of CO poisoning was made according to the medical history and carboxyhemoglobin (COHb) level of >5%. According to the carboxyhemoglobin levels, the patients were classified as mildly (COHb < 20%) and severely poisoned (COHb > 20%). In addition, patients were divided into 2 groups, i.e., those with positive (>0.05 ng/mL for our laboratory) and negative (<0.05 ng/mL for our laboratory) troponin levels.

RESULTS

Patients mean age was 52.58 ± 10.58. 57.9% of the patients had high troponin levels and 51.9% were poisoned severely according to COHb levels. Patients with positive troponin and COHb had longer CO exposure time and higher neutrophil, lymphocyte, mean platelet volume (MPV), COHb and red cell distribution width (RDW) levels at the index admission following CO poisoning than patients with negative troponin (p < 0.05). Age, COHb level, CO exposure time, MPV and RDW (p = 0.001, p < 0.05) remained associated with an increased risk of troponin positivity following adjustment for the variables that were statistically significant.

CONCLUSIONS

In patients presenting to the ED with CO poisoning, RDW and MPV can be helpful for risk stratification of neuropsychosis.

Non-ST elevation myocardial infarction induced by carbon monoxide poisoning: A case report

RATIONALE

Acute myocardial infarction is a rare complication of carbon monoxide poisoning. there is often no chest pain and other typical manifestations. We report a patient with mild carbon monoxide poisoning who had acute dyspnea as the earliest symptom and was later diagnosed with non-ST elevation myocardial infarction (NSTEMI) and acute left heart failure.

PATIENT CONCERNS

A 73-year-old woman complained of dizziness and fatigue with shortness of breath after carbon monoxide intoxication.

DIAGNOSES

This patient had a clear history of carbon monoxide poisoning, acute respiratory distress, bilateral lung dry and moist rale, chest X-ray showed bilateral pulmonary edema, Electrocardiograph indicated general depression of the ST segment of the leads in the chest, cardiac troponin I (CTNI) increased progressively, cardiac ultrasonography indicated abnormal ventricular wall movement, coronary angiography suggested left main trunk and 3-vessel lesions, suggesting diagnosis acute carbon monoxide poisoning, acute coronary syndrome, acute left heart failure.

INTERVENTIONS

She was treated with a high concentration of oxygen, an inhibitor of platelet aggregation (aspirin plus clopidogrel), an anticoagulant (low molecular weight heparin), an antimicrobial (ceftizoxime), an expectorant (mucosolvan), diuresis (furosemide and spironolactone), and myocardial support (Metoprolol). Coronary angiography and stent placement were performed 8 days later.

OUTCOME

On the 10th day after onset of the condition, echocardiography was performed, which showed that cardiac function was improved. Mild segmental wall motion abnormality was observed on echocardiography. After 14 days, the patient had recovered well and was discharged without chest tightness, chest pain, dizziness, headache, or unresponsiveness.

LESSONS

This case suggests that the symptoms of carbon monoxide poisoning are complex and diverse. It can be manifested as a primary hypoxic symptom, or cause the exacerbation of underlying diseases due to hypoxia. Therefore, patients with carbon monoxide poisoning should actively seek comprehensive cardiac examination to ensure early diagnosis. Whenever necessary, coronary angiography and stent implantation should be performed to improve the likelihood of the patient's survival.

Cardiovascular Abnormalities in Carbon Monoxide Poisoning

Acute carbon monoxide (CO) poisoning is the most common cause of poisoning and poisoning-related death in the United States. It manifests as broad spectrum of symptoms ranging from mild headache, nausea, and fatigue to dizziness, syncope, coma, seizures resulting in cardiovascular collapse, respiratory failure, and death. Cardiovascular complications of CO poisoning has been well reported and include myocardial stunning, left ventricular dysfunction, pulmonary edema, and arrhythmias. Acute myocardial ischemia has also been reported from increased thrombogenicity due to CO poisoning. Myocardial toxicity from CO exposure is associated with increased short-term and long-term mortality. Carboxyhemoglobin (COHb) levels do not correlate well with the clinical severity of CO poisoning. Supplemental oxygen remains the cornerstone of therapy for CO poisoning. Hyperbaric oxygen therapy increases CO elimination and has been used with wide variability in patients with evidence of neurological and myocardial injury from CO poisoning, but its benefit in limiting or reversing cardiac injury is unknown. We present a comprehensive review of literature on cardiovascular manifestations of CO poisoning and propose a diagnostic algorithm for managing patients with CO poisoning.

Non-ST elevation myocardial infarction secondary to carbon monoxide intoxication

Carbon monoxide poisoning has been documented in literature to cause severe neurological and tissue toxicity within the body. However, cardiotoxicity is often overlooked, but not uncommon. Previous research studies and case reports have revealed a significant relationship between carbon monoxide intoxication and myocardial ischemic events. We report a case of a 48-year-old male, who was exposed to severe smoke inhalation due to a house fire and subsequently developed a non-ST elevation myocardial infarction. Ischemic changes were evident on electrocardiogram, which demonstrated T-wave inversion in lead III and ST-segment depression in leads V4-V6. Elevated cardiac enzymes were also present. After standard treatment for an acute cardiac event, the patient fully recovered. This case demonstrates that myocardial ischemic changes due to carbon monoxide poisoning may be reversible if recognized in early stages and treated appropriately, thus reminding physicians that a proper cardiovascular examination and diagnostic testing should be performed on all patients with carbon monoxide poisoning. Abbreviations: NSTEMI: Non-ST elevation myocardial infarction.

Incidence and Clinical Course of Left Ventricular Systolic Dysfunction in Patients with Carbon Monoxide Poisoning

Background and Objectives

Carbon monoxide (CO) poisoning can cause tissue hypoxia and left ventricular systolic dysfunction (LVSD) requiring intensive medical management. Our objectives were to find incidence and clinical course of LVSD CO intoxicated patients and make a clinical scoring to predict LVSD.

Subjects and Methods

We included all consecutive patients with CO exposure in the emergency room. LVSD was defined by LVEF <50% assessed by echocardiography. We compared their clinical, chemical, radiological and electrocardiographic patterns according to the presence of LVSD.

Results

From May 2009 to June 2015, we included a total of 81 patients (48 men, 47±19 years old) with CO exposure in this cohort. LVSD was found in about 25 patients (31%). Nine had regional wall motion abnormality. Follow up echocardiographic examinations were available in 21 patients. Of them, 18 patients showed complete recovery in about 3 days (mean 2.8±1.7 days). Of 3 patients without recovery, 2 had significant coronary artery stenosis. LVSD was significantly associated with initial heart rate (>100/min), pulmonary edema on chest X-ray, serum NT pro-BNP (>100 pg/mL), troponin-I (>0.1 ng/mL) and lactic acid (>4.0 mg/dL) after a univariate analysis. Combining these into a clinical score, according to their beta score after a multivariate analysis (rage=0-16), allowed prediction of LVSD with a sensitivity of 84% and specificity of 91% (reference ≥8, area under the curve=0.952, p<0.001)

Conclusion

About 31% showed LVSD in patients with CO poisoning, and most of them (86%, 18 of 21 patients) recovered within 3 days. Patients with a higher clinical score (≥8) might have LVSD.

The Evaluation of Myocardial Damage in 83 Young Adults with Carbon Monoxide Poisoning in the East Anatolia Region in Turkey

Carbon monoxide (CO) poisoning is the leading cause of death from intoxication. In CO poisoning, it is important to know if there are any symptoms regarding myocardial damage, which are usually unobserved as a result of hypoxia. This study was planned to assess myocardial damage in young healthy patients with CO poisoning. Eighty-three young healthy cases who had been exposed to CO were included in this study. The demographic and clinical characteristics, the origin of CO gas and smoking habits of the patients were recorded. The evaluation of ECG, peripheral ABG, complete blood count and serial cardiac biomarkers (creatine kinase, creatine kinasemyocardial band and troponin I) measurements were performed in all cases. Additionally, echocardiogram (ECHO) and myocardial perfusion single-photon emission computed tomography (SPECT) were performed at the appropriate times in all cases. The mean age of the patients was 27.39 /10.9 years. The main complaint of the patients was loss of consciousness with a 62.7% rate. The average carboxyhaemoglobin level of the patients was 34.49 /15.9%. Sinus tachycardia was present in 26.5% of patients. Diagnostic ischaemic ECG changes were present in 14.4% of patients. In myocardial SPECT, myocardial ischaemic damage was observed in 9 cases, in 6 of whom ECHO findings were also confirmed. Myocar-dial damage due to CO poisoning should not be ignored. If patients are at risk in terms of myocardial damage, further studies, such as ECHO and scintigraphy are needed to determine myocardial damage resulting from CO poisoning. However, in the young adults of the risk group, if the baseline ECG and serial cardiac biomarkers are normal, further studies such as ECHO and scintigraphy, considering the length of exposure and the severity of poisoning, may not be necessary for the evaluation of myocardial damage due to CO poisoning.

An Interesting Cause of Pulmonary Emboli: Acute Carbon Monoxide Poisoning

Carbon monoxide poisoning, a public health problem of considerable significance, is a relatively frequent event today, resulting in thousands of hospitalizations annually. A 70-year-old lady was seen in the emergency department with a provisional diagnosis of carbon monoxide poisoning. The previous night, she slept in a tightly closed room heated with coal ember. She was found unconscious in the morning with poor ventilation. She had a rare presentation of popliteal vein thrombosis, pulmonary emboli, and possible tissue necrosis with carbon monoxide poisoning. Oxygen treatment with low-molecular-weight heparin (nadroparine) and warfarin therapy resulted in an improvement in both popliteal and pulmonary circulations. In conclusion, the presence of pulmonary emboli should be sought in patients with carbon monoxide poisoning.

[Myocardial stunning in carbon monoxide poisoning in a pregnant woman]

L'intoxication au monoxyde de carbone (CO) est la première cause de décès par intoxication en France. La littérature est ancienne et peu connue. Les signes les plus fréquents de l'intoxication sont la triade: Céphalées; asthénie, faiblesse musculaire surtout des membres inférieurs. Ses conséquences sont potentiellement graves pour le fœtus quand elle survient chez la femme enceinte, il est particulièrement exposé au risque d'hypoxie en raison de la forte affinité de son hémoglobine pour le CO qui traverse aisément le placenta. Les événements cardiovasculaires ne sont pas rares et peuvent être responsable d'une morbi-mortalité assez importante qui peuvent être d'apparition rapide ou secondaire mais régressent habituellement en quelques jours. Des SCA peuvent survenir lors d'une une intoxication au CO avec à l'extrême infarctus myocardique avec surélévation du segment ST. Il paraît légitime de proposer pour toutes les patientes: l’éloignement maternel de la source de CO; l'oxygénothérapie à 100% au masque facial par les services de secours et pendant le transfert; le traitement par oxygénothérapie hyperbare pour toutes les femmes enceintes, le plus rapidement possible et quelque soit l’âge gestationnel.

Carbon monoxide poisoning increases Tpeak-Tend dispersion and QTc dispersion

Objective

Carbon monoxide (CO) poisoning leads to cardiac dysrhythmia. Increased heterogeneity in ventricular repolarisation on electrocardiogram (ECG) shows an increased risk of arrhythmia. A number of parameters are used to evaluate ventricular repolarisation heterogeneity on ECG. The aim of our study is to investigate the effect of acute CO poisoning on indirect parameters of ventricular repolarisation on ECG.

Methods

Sixty-seven patients were included in this case–control study. Thirty patients with acute CO poisoning were assigned to group 1 (19 females, mean age: 30.8 ± 11.3 years). A control group was formed with patients without known cardiac disease (group 2, n = 37; 25 females, mean age: 26.0 ± 5.2 years). Twelve-lead ECG and serum electrolyte levels were recorded in all patients. Also, carboxyhaemoglobin (COHb) levels were recorded in group 1. T_peak–T_end (T_pT_e) interval, T_pT_e dispersion, T_pT_e/QT ratio, QT interval and QT_d durations were measured as parameters of ventricular repolarisation. Corrected QT (QT_c) and QT_c dispersion (QT_cd) intervals were determined with the Bazett’s formula.

Results

The mean COHb level in group 1 was 27.6 ± 7.4% and mean duration of CO exposure was 163.5 ± 110.9 min. No statistically significant difference was found in age, gender, serum electrolytes or blood pressure levels between the groups. QRS, QT, QT_c, T_pT_e interval and T_pT_e/QT ratio were similar between the groups (p > 0.05). QTcd (65.7 ± 64.4 vs 42.1 ± 14.2 ms, p = 0.003) and T_pT_e dispersion (40.5 ± 14.8 vs 33.2 ± 4.9 ms, p = 0.006) were significantly longer in group 1 than group 2. COHb level was moderately correlated with TpTe dispersion (r = 0.29; p = 0.01).

Conclusion

To our knowledge, this is the first study to investigate T_pT_e interval and dispersion in CO poisoning. Our results showed that T_pT_e dispersion and QTc dispersion increased after CO poisoning.

Thrombolytic therapy in a patient with inferolateral myocardial infarction after carbon monoxide poisoning

INTRODUCTION

ST segment elevation myocardial infarction (STEMI) due to coronary artery occlusion caused by intracoronary thrombosis in the setting of acute carbon monoxide (CO) poisoning is a very rare presentation. We present a case of intracoronary large and mobile thrombus formation after CO poisoning.

CASE PRESENTATION

A previously healthy 50-year-old woman was referred for CO poisoning. She had chest pain after exposure to CO. Her initial mental status was preoccupied with chest pain. Her initial CO fraction was 28.1%, and initial laboratory data showed creatine kinase-myocardial isoenzyme of 134 U/L (upper limit 25 U/L) and troponin I of >50 ng/mL (upper limit 0.06 ng/mL). Electrocardiography was carried out on admission, revealing an ST segment elevation in the inferolateral leads. After initial evaluation, coronary angiography was performed and an intracoronary large mobile thrombus was seen in the proximal left anterior descending (LAD) artery with no significant stenosis. We administered tenecteplase with heparin. After the thrombolytic therapy, ST elevation in the inferolateral leads resolved. Repeat angiography was performed after 24 h; the thrombus in LAD had resolved. The patient was discharged after 5 days, with persistent Q wave in the inferior leads and mild hypokinesia of the inferoposterior wall suggesting myocardial injury.

CONCLUSION

We describe intracoronary thrombus formation induced by CO poisoning. Because intracoronary thrombus can result in myocardial infarction, its consideration following CO poisoning is important. Patients with CO poisoning who have symptoms of STEMI should be carefully evaluated with serial electrocardiograms, cardiac biomarkers, and an echocardiogram. When there is evidence of acute myocardial injury, a primer in coronary angiography can determine which patients could benefit from intervention.

[Acute coronary syndrome with impaired left ventricular function in a carbon monoxide poisoning]

Carbon monoxide poisoning is the leading cause of death by poisoning in France. Neuropsychological symptoms are most common. We report on a patient with acute coronary syndrome and transient left ventricular dysfunction in carbon monoxide poisoning. Patient improved under hyperbaric oxygen therapy. Coronary angiography shows no significant lesion leading to myocardial stunning diagnose. Patients exposed to carbon monoxide must have systematic cardiac evaluation with electrocardiogram and dosage of biomarkers.

Carbon monoxide: Anticoagulant or procoagulant?

Within the past decade there have been several investigations attempting to define the impact of exogenous and endogenous carbon monoxide exposure on hemostasis. Critically, two bodies of literature have emerged, with carbon monoxide mediated platelet inhibition cited as a cause of in vitro human and in vitro/in vivo rodent anticoagulation. In contrast, interaction with heme groups associated with fibrinogen, α₂-antiplasmin and plasmin by carbon monoxide has resulted in enhanced coagulation and decreased fibrinolysis in vitro in human and other species, and in vivo in rabbits. Of interest, the ultrastructure of platelet rich plasma thrombi demonstrates an abnormal increase in fine fiber formation and matting that are obtained from humans exposed to carbon monoxide. Further, thrombi obtained from humans and rabbits have very similar ultrastructures, whereas mice and rats have more fine fibers and matting present. In sum, there may be species specific differences with regard to hemostatic response to carbon monoxide. Carbon monoxide may be a Janus-faced molecule, with potential to attenuate or exacerbate thrombophilic disease.

Mild carbon monoxide poisoning impairs left ventricular diastolic function

Rationale:

Carbon monoxide (CO) poisoning is associated with direct cardiovascular toxicity. In mild CO poisoning in which cardiovascular life support is not required, the effects of CO on left and right ventricular functions are unknown in patients without cardiac failure.

Objectives:

Echocardiography was used to determine whether or not mild CO poisoning impairs ventricular function. Twenty otherwise healthy patients with CO poisoning and 20 age- and gender-matched controls were studied. Echocardiographic examinations were performed at the time of admission and 1 week after poisoning.

Results:

The impairment observed in the left and right ventricular diastolic function at the time of admission was greater than the impairment 1 week after poisoning. Mild CO poisoning did not have a significant effect on systolic function. Carboxyhemoglobin levels were positively correlated with left ventricular diastolic dysfunction, whereas the levels were not correlated with right ventricular diastolic function.

Conclusions:

In CO intoxication, the development of left and right ventricular diastolic dysfunction precedes systolic abnormality. Patients with mild CO poisoning do not manifest cardiovascular symptoms; however, it should be borne in mind that most of these patients have myocardial involvement.

Mean Platelet Volume in Patients With Carbon Monoxide Poisoning

Carbon monoxide (CO) poisoning is frequent and can lead to high morbidity and mortality. Some studies have indicated increased platelet activation and aggregation in CO poisoning. Thus, we investigated mean platelet volume (MPV), an indicator of platelet activation, in patients with CO poisoning. We included 193 (117 women) patients who presented with a diagnosis of CO poisoning between June 2011 and March 2013. Control group was composed of 39 (15 women) patients. Troponin and creatine kinase MB levels were significantly higher in the CO poisoning group. Platelet counts were significantly higher in patients with CO poisoning (281 ± 76 vs 248 ± 65 × 109, respectively; P = .01). Similarly, MPV was significantly higher in the CO poisoning group (8.9 ± 0.8 vs 7.9 ± 0.9 fL, respectively; P < .001). Elevated MPV values may indicate that patients with CO poisoning have a higher risk of thromboembolic and cardiovascular complications due to platelet activation.

Carbon monoxide poisoning

Carbon monoxide (CO) poisoning is the leading cause of death as a result of unintentional poisoning in the United States. CO toxicity is the result of a combination of tissue hypoxia-ischemia secondary to carboxyhemoglobin formation and direct CO-mediated damage at a cellular level. Presenting symptoms are mostly nonspecific and depend on the duration of exposure and levels of CO. Diagnosis is made by prompt measurement of carboxyhemoglobin levels. Treatment consists of the patient's removal from the source of exposure and the immediate administration of 100% supplemental oxygen in addition to aggressive supportive measures. The use of hyperbaric oxygen is controversial.

Intracardiac thrombus formation induced by carbon monoxide poisoning

INTRODUCTION

Carbon monoxide (CO) is one of the leading causes of poisoning; it inhibits oxygen delivery, subsequently causing ischemic changes and ultimately death by multiorgan failure. Furthermore, thromboembolic episodes due to CO poisoning have been reported. However, intracardiac thrombus formation following exposure to CO has been very rarely described. Here, a case of right atrial large thrombus formation after CO poisoning is presented.

CASE PRESENTATION

A previously healthy 24-year-old woman was referred for CO poisoning. She has attempted suicide, and her initial mental status was drowsy with focal memory loss. Her initial CO fraction was 16%, and initial laboratory data showed creatinine kinase-myocardial bound of 90.6 ng/mL (upper limit 5 ng/mL) and troponin I of 1.899 ng/mL (upper limit 1.5 ng/mL). A transthoracic echocardiography was performed 24 h after the accident, revealing a 30 15 mm nodular echogenic mass in the right atrium. Anticoagulation with low-molecular-weight heparin was started along with hyperbaric oxygen therapy. After 7 days of heparinization, the large thrombus in right atrium had resolved.

CONCLUSION

This report describes an intracardiac thrombus formation induced by CO poisoning. Because intracardiac thrombus can result in pulmonary embolism and cerebral embolic infarction, its consideration following CO poisoning is important.

A case of carbon monoxide poisoning with thrombus in right atrium

Carbon monoxide is a nonirritant, odorless, colorless gas. Its effects are prominent in organs most sensitive to oxygen deprivation, such as the heart, brain, and kidney. Although less frequently, an association between thromboembolic events and carbon monoxide poisoning has been shown in the literatures. In this case, we report a case of atrial thrombus associated with carbon monoxide poisoning.

A Case of Acute Carbon Monoxide Poisoning Resulting in an ST Elevation Myocardial Infarction

Carbon monoxide (CO) is a well-known chemical asphyxiant, which causes tissue hypoxia with prominent neurological and cardiovascular injury. After exposure to CO, several cardiac manifestations have been reported, including arrhythmias, acute myocardial infarction, and pulmonary edema. However, an ST elevation myocardial infarction (STEMI) due to CO poisoning is a very rare presentation, and the treatment for STEMI due to CO poisoning is not well established. Here, we report a rare case of STEMI complicated by increased thrombogenicity secondary to acute CO poisoning and complete revascularization after antithrombotic treatment.

How and why chemicals from tobacco smoke can induce a rise in blood pressure

The primary objective of this article is to analyze the role of tobacco smoke compounds able to damage the cardiovascular system and, in particular, to interfere with blood pressure. They are products of tobacco plant leaves, like nicotine, thiocyanate and aromatic amines, and a chemical derived from cigarette combustion, carbon monoxide. Of the other thousands of chemicals, there is no clear evidence of cardiovascular damage. Nicotine and its major metabolite, cotinine, usually increase blood pressure by a direct action and an action stimulating neuro-humoral metabolites of the body as well as sympathetic stimulation. An indirect mechanism of damage exerted by elevated carboxyhemoglobin concentrations is mediated by carbon monoxide, which, mainly induces arterial wall damage and, consequently, late rising in blood pressure by a toxic direct action on endothelial and blood cells. Thiocyanate, in turn, reinforces the hypoxic effects determined by carbon monoxide. Aromatic amines, depending on their chemical structure, may exert toxic effects on the cardiovascular system although they have little effect on blood pressure. A rise in blood pressure determined by smoking compounds is a consequence of both their direct toxicity and the characteristics of their chemical chains that are strongly reactive with a large number of molecules for their spatial shape. In addition, a rise in blood pressure has been documented in individuals smoking a cigarette, acutely and chronically, with irreversible artery wall alterations several years after beginning smoking. Since cigarette smoking has a worldwide diffusion, the evidence of this topic meets the interest of both the scientific community and those individuals aiming to control smoking.

H-FABP in cases of carbon monoxide intoxication admitted to the emergency room

INTRODUCTION

Carbon monoxide (CO) intoxication causes cardiovascular problems as a result of diffuse tissue hypoxia. Cardiac biochemical markers and electrocardiographic changes have been reported in CO intoxications. Human fatty acid-binding protein (H-FABP) has been recently used as a reliable marker in identifying early cardiac damage. In this prospective study, we aimed to investigate the advantages of the use of H-FABP, in evaluating the findings of myocardial ischemia in patients with CO intoxication in our region.

METHODS

Twenty four successive patients admitted to the emergency department with acute CO intoxication were included in our study. Serum traditional markers and H-FABP were also taken in the earliest period for evaluation of cardiac damage.

RESULTS

The creatinine kinase MB (CKMB) levels were positive in 11 of the patients; however, H-FABP and troponin T levels were positive in only 3 of them. One of these subjects had elevated level of H-FABP in the short-term and increasing troponin T level increasing level of troponin T during the follow-up period.

CONCLUSION

The obtained data supports the use of H-FABP, a specific indicator in identifying the cardiotoxicity of CO intoxications at an early phase.

Transient left ventricular systolic dysfunction associated with carbon monoxide toxicity

Carbon monoxide (CO) is one of well known chemical asphyxiants which cause tissue hypoxia with prominent neurologic and cardiovascular injury. Cardiac dysfunction after CO poisoning can be presented as two clinical patterns. One is transient global left ventricular (LV) dysfunction and the other is LV dysfunction with regional wall motion abnormalities. In this case report, we present a case with transient LV systolic dysfunction caused by intentional exposure to CO. After conservative treatment including high concentration of oxygen, the patient recovered completely without any complication.

Air Pollution and Hospital Admissions for Congestive Heart Failure in a Tropical City: Kaohsiung, Taiwan

This study was undertaken to determine whether there was an association between air pollutant levels and hospital admissions for congestive heart failure (CHF) in Kaohsiung, Taiwan. Hospital admissions for CHF and ambient air pollution data for Kaohsiung were obtained for the period 1996-2004. The relative risk of hospital admission was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant models, on warm days (> 25 degrees C) statistically significant positive associations were found in all pollutants except sulfur dioxide (SO(2)). On cool days (< 25 degrees C), all pollutants were significantly associated with CHF admissions. For the two-pollutant model, CO and O(3) were significant in combination with each of the other four pollutants on warm days. On cool days, NO(2) remained statistically significant in all the two-pollutant models. This study provides evidence that higher levels of ambient air pollutants increase the risk of hospital admissions for CHF and that the effects of air pollutants on hospital admissions for CHF were temperature dependent.

Air pollution and hospital admissions for congestive heart failure in a subtropical city: Taipei, Taiwan

This study was undertaken to determine whether there was an association between air pollutant levels and hospital admissions for congestive heart failure (CHF) in Taipei, Taiwan. Hospital admissions for CHF and ambient air pollution data for Taipei were obtained for the period from 1996 to 2004. The relative risk of hospital admission was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant model, the number of CHF admissions was significantly associated with the environmental presence of the contaminants particulate matter (PM(10)), nitrogen dioxide (NO(2)), carbon monoxide (CO), and ozone (O(3)) on warm days (>20 degrees C). However, statistically significant positive effects on increased CHF admissions on cool days (<20 degrees C) was observed only for CO levels. For the two-pollutant model, NO(2) and O(3) were significant in combination with each of the other four pollutants on warm days for enhanced CHF admissions. This study provides evidence that higher levels of ambient air pollutants increase the risk of hospital admissions for CHF.

Serum levels of NT-ProBNP as an early cardiac marker of carbon monoxide poisoning

Acute carbon monoxide (CO) poisoning may cause cardiotoxicity. The natriuretic peptides, including atrial natriuretic peptide, brain natriuretic peptide (BNP), N-BNP, and NT-proBNP (N-terminal pro brain natriuretic peptide), are endogenous cardiac hormones that may be secreted upon myocardial stress. The aim of this study was to assess the plasma NT-proBNP level in acute CO poisoning and to compare it with healthy control. After approval by the ethical committee, 15 healthy controls and 15 patients admitted to the Gaziantep University Hospital (Gaziantep, Turkey) between January 2005 and July 2005 with the diagnosis of carbon monoxide poisoning were studied. Echocardiography was performed to all patients. Serum NT-proBNP, creatine kinase (CK), creatine kinase-MB (CK-MB), and troponin-T were also analyzed, along with the carboxyhemoglobin (COHb) level. The correlation between serum NT-proBNP and COHb level was investigated. Electrocardiography (ECG) was performed to all patients and healthy controls, and the results were compared. Differences in troponin, CK, and CK-MB levels were not statistically significant between groups (p > 0.05). The level of NT-proBNP and COHb were found to be increased in the study group. There was a positive correlation between the COHb and the NT-proBNP (r = 0.829, p < 0.01), and between the COHb and the CK (r = 0.394, p < 0.01). There was no difference between groups in other parameters, all of which were within normal range. Thus, in this study we showed that the plasma NT-proBNP level may contribute to the early diagnosis of cardiotoxicity in patients with carbon monoxide poisoning.

Effects of ambient particles and carbon monoxide on supraventricular arrhythmias in a rat model of myocardial infarction

The association between short-term increases in particulate air pollution and increased cardiovascular morbidity and mortality is well documented. Recent studies suggest an association between particulate matter with aerodynamic diameter < 2.5 microm (PM2.5) and supraventricular arrhythmias (SVA), but the results have been inconsistent. We evaluated this hypothesis in a rat model of acute myocardial infarction (AMI). Diazepam-sedated Sprague-Dawley rats with AMI were exposed (1 h) to either filtered air (n = 16), concentrated ambient fine particles (CAPS; mean = 645.7 microg/m3; n = 23), carbon monoxide (CO; 35 ppm; n = 19), or CAPs and CO (n = 24). Each exposure was immediately preceded and followed by a 1-h exposure to filtered air (baseline and postexposure periods, respectively). Surface electrocardiograms were recorded and the frequency of supraventricular premature beats was quantified. Among rats in the CAPS group, the probability of observing any SVA decreased from baseline to the exposure and postexposure periods. This pattern was significantly different than that observed for the filtered air group during the exposure period (p = .048) only. In the subset of rats with one or more SVA during the baseline period, the change in SVA rate from baseline to exposure period was significantly lower in the CAPS (p = .04) and CO (p = .007) groups only, as compared to the filtered air group. No significant effects were observed in the group simultaneously exposed to CAPS and CO. Thus, the results of this study do not support the hypothesis that exposure to ambient air pollution increases the risk or frequency of supraventricular arrhythmias.

Myocardial dysfunction and potential cardiac hypoxia in rats induced by carbon monoxide inhalation

BACKGROUND

Results from both animal and human being studies provide evidence that inhalation of concentrations of carbon monoxide (CO) at around 100 ppm has antiinflammatory effects. These low levels of CO are incriminated in ischemic heart diseases experienced by cigarette smokers and, in some cases, from air pollution. Although neurologic mechanisms have been investigated, the effects of CO on cardiovascular function are still poorly understood.

METHODS AND RESULTS

The effects of CO (250 ppm; 90 min) inhalation on myocardial function were investigated in isolated heart of rats killed immediately, and 3, 24, 48, and 96 h after CO exposure. CO exposure at 250 ppm resulted in an arterial carboxyhemoglobin (HbCO) level of approximately 11%, which was not associated with changes in mean arterial pressure and heart rate. CO exposure induced coronary perfusion pressure increases, which were associated with endothelium-dependent and -independent vascular relaxation abnormalities. CO-induced coronary vascular relaxation perturbations were observed in the presence of increased heart contractility. Spontaneous peak to maximal Ca(2+)-activated left ventricular pressure ratio was markedly increased in CO-exposed rats, indicating increases in myofilament calcium sensitivity. Heart cyclic guanosine monophosphate/cAMP ratio and myocardial permeabilized fiber respiration (complex intravenous activity) were reduced in CO-exposed rats, which lasted after 48 h of reoxygenation in air.

CONCLUSIONS

These findings suggest that CO deteriorates heart oxygen supply to utilization and potentially may induce myocardial hypoxia through mechanisms that include increased oxygen demand due to increased contractility, reduced coronary blood flow reserve, and cardiomyocyte respiration inhibition.

Toxicity Associated with Carbon Monoxide

Carbon monoxide is an insidious poison that accounts for thousands of deaths each year in North America. Clinical effects maybe diverse and include headache, dizziness, nausea, vomiting,syn-cope, seizures, coma, dysrhythmias, and cardiac ischemia. Children, pregnant women, and patients who have underlying cardiovascular disease are particularly at risk for adverse out-comes. Treatment consists of oxygen therapy, supportive care, and, in selected cases, hyperbaric oxygen therapy.

Carbon monoxide poisoning

CO is an ubiquitous poison with many sources of exposure. CO poisoning produces diverse signs and symptoms that are often subtle and may be easily misdiagnosed. Failure to diagnose CO poisoning may result insignificant morbidity and mortality and permit continued exposure to a dangerous environment. Treatment of CO poisoning begins with inhalation of supplemental oxygen and aggressive supportive care. HBOT accelerates dissociation of CO from hemoglobin and may also prevent DNS. Absolute indications forHBOT for CO poisoning remain controversial, although most authors would agree that HBOT is indicated in patients who are comatose or neurologically abnormal, have a history of LOC with their exposure, or have cardiac dysfunction. Pregnancy with an elevated CO-Hgb level(>15%-20%) is also widely, considered an indication for treatment.HBOT may be considered in patients who have persistent symptoms despite NBO, metabolic acidosis, abnormalities on neuropsychometric testing, or significantly elevated levels. The ideal regimen of oxygen therapy has yet to be determined, and significant controversy exists regarding HBOTtreatment protocols. Often the local medical toxicologist, poison control center, or hyperbaric unit may assist the treating physician with decisions regarding therapy.

Cardiovascular manifestations of moderate to severe carbon monoxide poisoning

OBJECTIVES

We describe the cardiovascular manifestations of carbon monoxide (CO) poisoning.

BACKGROUND

Carbon monoxide poisoning is a common cause of toxicologic morbidity and mortality. Although the neurologic sequelae of CO poisoning have been well described, the cardiovascular consequences are limited to isolated case reports.

METHODS

We reviewed the cardiovascular manifestations of 230 consecutive patients treated for moderate to severe CO poisoning in the hyperbaric oxygen chamber at Hennepin County Medical Center (HCMC), a regional center for treatment of CO poisoning.

RESULTS

The mean age was 47.2 years with 72% men. Ischemic electrocardiogram (ECG) changes were present in 30% of patients, whereas only 16% had a normal ECG. Cardiac biomarkers (creatine kinase-MB fraction or troponin I) were elevated in 35% of patients. In-hospital mortality was 5%.

CONCLUSIONS

Cardiovascular sequelae of CO poisoning are frequent, with myocardial injury assessed by biomarkers or ECG in 37% of patients. Patients admitted to the hospital with CO poisoning should have a baseline ECG and serial cardiac biomarkers.