Is this 23 year old having a myocardial infarction? COPYRIGHT © 2013, ALL RIGHTS RESERVED From the Publishers of
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Copyright © 2013 Case 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
Copyright © 2013 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
Copyright © 2013 EKG
Copyright © yo with MI You have diagnosed acute myocardial infarction and are arranging for emergency coronary angiography. While awaiting cath the following lab test results become available:
Copyright © 2013 Labs: CBC: wnl Electrolytes: wnl Renal and hepatic function: wnl Urine drug screen: wnl Troponin I yo with MI
Copyright © 2013 From Gordon JB, et al.: j Am Coll cardiol 2009:54:1911 Cath
Copyright © 2013 In attempting to find the cause of the cath finding you ask the patient for permission to speak with: His athletic coach His fraternity brothers His parents His girlfriend His travel agent 23 yo with MI
Copyright © 2013 Case 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
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Copyright © 2013 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
Copyright © 2013 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 Myocardial infarction in men younger than age 45
Copyright © 2013 Kawasaki Disease Leading cause of acquired heart disease in children in developed world Age < 5, Febrile illness, mucocutaneous changes
Copyright © 2013 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
Copyright © 2013 Kawasaki Disease Cause? Autoimmune, infection, genetic susceptibility 25% develop coronary artery aneurysm IVIG + ASA during first 10 days decrease aneurysm formation to 3-5% Symptomatic adult 20 years later
Copyright © 2013 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
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