Canadian Neighbor Pharmacy: Acute Posteroinferior Wall Myocardial Infarction Secondary to Football Chest Trauma

29 Oct
2015

Trauma to the heartTrauma to the heart after nonpenetrating injury is well recognized. Among the recorded consequences are cardiac arrhythmias, septal damage, valve damage, coronary fistulae, coronary artery damage, ventricular aneurysm, cardiac rupture, and myocardial infarction (MI). Myocardial infarction as a complication of chest trauma has been reported in very few cases and usually is secondary to an automobile accident. In the present report, we describe a patient who developed acute ischemia manifested by posteroinferior wall MI (API-MI) secondary to a football chest trauma.

Case Report

A 33-year -old white sportsman without any previous history of heart disease, was admitted to the coronary care unit because of severe chest pain after straight anterior wall chest trauma by a football. At the same time, the patient complained of dyspnea, nausea, and vomiting. His physical examination on arrival revealed blood pressure of 140/80 mm Hg, regular pulse rate of 68 beats per minute, and respiration at the rate of 22 per minute. Carotid and jugular venous pulsations were normal. Examination of the chest wall showed no sign of injury. Auscultation of the lungs was normal. The first and second heart sounds were normal, and an apical S4 gallop was present No murmur or rub were heard. Examination of the abdomen and extremities was normal. The electrocardiogram (ECG) on admission showed an API-MI (Fig 1), chest x-ray film was normal. Creatine kinase (CK) value was 1,077 U (normal 0-50 U) with a CK-MB fraction of 19.6 percent (normal, less than 5 percent). Echocardiogram revealed an area of hypokinesia on the inferior wall and interventricular nauseaseptum; the right ventricle was normal. Myocardial scintigraphy with technetium 99m pyrophosphate was performed on the third hospital day and was compatible with necrosis of the inferior wall, inferior third of the interventricular septum, and the right ventricle (Fig 2). On the 12th hospital day, the submaximal stress test with thallium-201 was positive for the inferior wall. The left ventriculogram showed an area of akinesia on the posteroinferior wall, and the coronary angiography revealed total obstruction of the proximal right coronary artery (Fig 3). The patient had an uneventful hospitalization, and three weeks after admission, he was discharged asymptomatic and without medication. More information about medications and diseases you may on Canadian Neighbor Pharmacy twitter official group.

Discussion

Nonpenetrating chest traumas producing different cardiac complications have been reported frequently. However among these complications, MI has been documented in only a few cases and usually secondary to automobile accidents. The anatomic position of the coronary circulation facilitates that the anterior descending coronary artery is the coronary vessel most frequently affected in this type of chest trauma. On reviewing the literature, we found only two cases of AMI secondary to football chest trauma. Both cases showed anterior wall MI. We, therefore, wish to add a new case with this complication, in whom an acute inferior wall MI developed.

The mechanism by which nonpenetrating chest trauma may be complicated with an AMI is not defined yet; however, the factors capable of producing an AMI in this setting are mainly coronary thrombosis and/or spasm of a normal coronary artery. The coronary angiography performed in our patient three weeks after the event revealed a complete obstruction of the main right coronary artery, which we really think was secondary to the chest trauma and not due to previous heart disease, mainly because of the patients youth.

We believe that all patients with chest trauma should have the following: complete physical examination, resting ECG, chest x-ray film, echocardiogram, and CK-MB. In finding abnormalities such as rupture of any heart structure or MI, we consider it necessary to perform angiographic study.

Figure-1

Figure 1. Twelve-lead ECG showing sinus rhythm with posteroinferior wall myocardial infarction.

Figure-2

Figure 2. Myocardial scintigraphy with technetium 99m pyrophosphate reveals necrosis of the inferior wall (IW), inferior third of the interventricular septum (S), and right ventricle (RV).

Figure-3

Figure 3. (a) Coronary angiogram of the left coronary artery from a right anterior oblique view, showing normal cincumflex, marginal and anterior descending arteries, (b) Coronary angiogram of the right coronary artery from the same view, revealing complete proximal obstruction.

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