1. Is this 23 year old having a myocardial infarction? COPYRIGHT © 2013, ALL RIGHTS RESERVED From the Publishers of

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3. 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

4. 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

5. Copyright © 2013 EKG

6. Copyright © 2013 23 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:

7. Copyright © 2013 Labs:  CBC: wnl  Electrolytes: wnl  Renal and hepatic function: wnl  Urine drug screen: wnl  Troponin I 5.0 23 yo with MI

8. Copyright © 2013 From Gordon JB, et al.: j Am Coll cardiol 2009:54:1911 Cath

9. 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

10. 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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12. 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

13. 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

14. Copyright © 2013 Kawasaki Disease Leading cause of acquired heart disease in children in developed world Age < 5, Febrile illness, mucocutaneous changes

15. 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

16. 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

17. 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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