Stumper: Too Young for Chest Pain

Stumper A 23 yo man presents to the ED with 4 hours of chest pain –Healthy Denies cigarette smoking, FHx, DM, Hypertension. Unaware of lipid status No family hx of thrombotic disorder No use of food supplements, additives, anabolic steroids, etc –Brief episode of vague chest pain yesterday –Student –Moderate physical exercise but no strenuous exercise

Stumper Exam –Diaphoretic and in pain –Ht 5’8”, wt 150 lbs –BP 120/80 right and left arm, HR 95 (sinus) –S1, S2 normal, No murmurs, S3, S4 –Abd soft, bowel sounds normal –Distal pulses intact. No edema

Stumper

You have diagnosed acute myocardial infarction and are arranging for emegency coronary angiography. While awaiting cath the following lab test results become available:

Stumper Labs: –CBC: wnl –Electrolytes: wnl –Renal and hepatic function: wnl –Urine drug screen: wnl –Troponin I 5.0

Stumper Cath From Gordon JB, et al.: j Am Coll cardiol 2009:54:1911

Stumper In attempting to find the cause of the cath finding you ask the patient for permission to speak with : 1.His athletic coach 2.His fraternity brothers 3.His parents 4.His girlfriend 5.His travel agent

Stumper 23 year old man Acute diaphragmatic myocardial infarction –Aneurysm of the right coronary artery with thrombus No cardiac risk factors No strenuous exercise Denies cocaine use Drug screen negative

Our “Consult Guys ” Research Interns

Myocardial infarction in men younger than age 45 Frequently heavy smokers MI often first evidence of coronary disease –< 1 week of pre-MI symptoms High incidence of “single vessel” disease (normal in 20%) Cocaine –Coronary artery spasm, hypercoagulable, accelerated atherosclerosis, hypertension, arrhythmia

Myocardial infarction in men younger than age 45 Congenital coronary anomaly Hypercoagulable state –Antiphospholipid antibody syndrome ( hx of recurrent venous and arterial thrombosis –Factor V Leiden (smoking increases MI risk) Spontaneous coronary artery dissection –Women, peripartum –Ehlers Danlos, Marfans –During or after strenuous exercise –Cocaine Septic embolus to coronary artery Coronary artery aneurysm with thrombosis

Kawasaki Disease Leading cause of acquired heart disease in children in developed world Age < 5, Febrile illness, mucocutaneous changes

What does the parent remember? Age < 5 Fever > 102 for > 4 days Bloodshot eyes Strawberry tongue Red palms, soles Rash middle body Desquamation fingers No response to antipyretics

Kawasaki Disease Leading cause of acquired heart disease in children in developed world Age < 5, Febrile illness, mucocutaneous changes Cause? Autoimmune, infection, genetic sussceptibility 25% develop coronary artery aneurysm –IVIG + ASA during first 10 days decrease aneurysm formation to 3-5% Symptomatic adult 20 years later

Adult with history Kawasaki Disease No Data No coronary dilatation followed acute episode –Noninvasive coronary testing every 3-4 years Coronary artery aneurysm – no symptoms –Noninvasive testing every 6 months –Coronary angio every 2-3 years (??? CT) –Low dose aspirin –Giant aneurysm (>7 mm) warfarin Coronary artery aneurysm – symptoms –More frequent noninvasive testing –Angiography as needed