Is this 23 year old having a myocardial infarction? COPYRIGHT © 2013, ALL RIGHTS RESERVED From the Publishers of
Is this 23 year old having a myocardial infarction? COPYRIGHT © 2013, ALL RIGHTS RESERVED From the Publishers of.
Dec 22, 2015
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Is this 23 year old having a myocardial infarction?
COPYRIGHT © 2013, ALL RIGHTS RESERVED
From the Publishers of
Copyright © 2013
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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
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Exam
Diaphoretic and in painHt 5’8”, wt 150 lbsBP 120/80 right and left arm, HR 95 (sinus)S1, S2 normal, No murmurs, S3, S4Abd soft, bowel sounds normalDistal pulses intact. No edema
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EKG
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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:
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Labs:
CBC: wnl Electrolytes: wnl Renal and hepatic function: wnl Urine drug screen: wnl Troponin I 5.0
23 yo with MI
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From Gordon JB, et al.: j Am Coll cardiol 2009:54:1911
Cath
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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
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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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Our “Consult Guys” Research Interns
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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
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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
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Kawasaki Disease
Leading cause of acquired heart disease in children in developed world
Age < 5, Febrile illness, mucocutaneous changes
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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
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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
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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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