intracoronary thrombolytic therapy in a patient with st ......intracoronary thrombolytic therapy in...

IntracoronaryThrombolyticTherapyinaPatientwithSTElevationMyocardialInfarctionintheSettingofCarbonMonoxidePoisoning.

IlianaHurtadoRendón MD,AhmadAbdin MD,Yesha PatelMD,WilliamBaumanMD,KevinSilverMD,MBS,FACC,FSCAI,FASNC

SummaHealthSystem,AkronCityHospital,Akron,OH

Figure1:EKGonPresentation Results/ReviewofLiterature• Thepatientdidnotsufferlongtermcomplicationandwas

followedupintheoutpatientsetting.• ThreemonthrepeatTTErevealedimprovementintheinferior

wallmotionabnormality.Apicalmyocardialakinesis remained.Ejectionfractionwasnormalat58%.

• IntracoronarythrombusisararecomplicationofCOpoisoningwithonly7reportedcasesintheliterature.

• Includingourpatient,5/8(62.5%)reportedweremen;agerange30-70yearsoldwithamean48.5years.

• Allpatientscomplainedofchestpain,exhibitedEKGchanges,andwerediagnosedatcardiaccatheterization.

• 3/8(37.5%)weretreatedbyballoonangioplasty,1/8(12.5%)wasnottreatedduetoconditionbeingfoundonpost-mortemautopsy,1/8(12.5%)treatedwithdrug-elutingstentplacement,1/8(12.5%)viahyperbaricchamber,1/8(12.5%)withsystemicthrombolytic,and1/8(12.5%)withcombinationofintracoronarythrombolytic,aspirationthrombectomy,andsystemicanticoagulation.[Figure7]

• All8(100%)werefoundtohaveathrombusintheLADartery.• 5/8(62.5%)hadcardiovascularriskfactorsorpreviouscardiac

events.• 7/8(87.5%)ofpatientssurvived.• Ourcaseinvolvestheyoungestpatientandisthefirsttobe

treatedwith acombinationofunfractionatedheparin,glycoprotein2b/3ainhibitor,intracoronarythrombolytic,aspirationthrombectomy,andoralanticoagulation.

Conclusions1. IntracoronarythrombusisararecomplicationofCOpoisoning.2. 100%ofpatientsreportedpresentedwithchestpain.3. PatientswereevaluatedwithserialEKG’s,cardiacbiomarkers,

andaTTE.Coronaryangiographyshouldbeconsideredwhenthereisevidenceofmyocardialinjury.

4. Theleftanteriordescendingarteryisthemostcommonlocationforthrombusformation.

5. Anti-thrombotictreatmentiscriticalwhenmyocardialinfarctionissuspected.

CaseRelevance• CarbonMonoxide(CO)isacolorlessandodorlesschemical

asphyxiantthatcausestissuehypoxiaresultinginmanifestationsinmultiplemajororgansincludingtheheart.

• Themechanismofmyocardialinjuryinvolves demandischemiawithorwithoutunderlyingcoronaryatherosclerosis.Fibrinolyticpathwayactivation duetoendothelialdamagefromoxygen-freeradicalsmayalsocontribute.

• WereportacaseofSTelevationmyocardialinfarctionduetoaleftanteriordescendingarterythrombusasararecomplicationfromacuteCOpoisoningandreviewallpatientsreportedintheliteratureinthe21st century.

PresentingHistory• History:32yearoldmalesummonedEMSforcomplaintsof

chestdiscomfort,headache,andnausea.Chestdiscomfortwasdescribedasaconstant,anteriorchestachewithoutradiationandassociatedwithnausea.Durationwas5hours.

• Itwasdiscoveredthatthepatientwasheatinghisapartmentbyleavingthedoorofhisgasovenopen.

• PastMedicalHistory: Hypertension• PhysicalExam.VS:BP=143/79;P=92/min.;R=22/min.

Patientwasnotinacutedistressonnon-rebreathermaskandmentationwasnormal.Lungswerecleartoauscultation.Cardiacexaminationrevealednormalrateandrhythmwithoutmurmurs,rubs,orgallops.Bedsidetransthoracicechocardiogramwasnotsignificantforpericardialeffusionorwallmotionabnormality.

• Lab.Carboxyhemoglobin:13.8.TroponinI:0.126.CKMB:115.CKMBIndex:4.5.Electrolytes:withinnormallimits

• Electrocardiogram(EKG):Normalsinusrhythm.ProlongedPRinterval.DiffuseSTelevations.[Figure1]

HospitalCourse• Patientwasadmittedtotelemetryandremainedwithout

furtherepisodesofchestpain.Overnight,TroponinIincreasedto10.7.CK-MBpeakedat168.

• Imaging:Transthoracicechocardiogram(TTE)wassignificantforwallmotionabnormalitiesintheapex,apical-inferior,septal,andapical-anteriormyocardialwalls.Ejectionfraction(EF)wasestimatedtobe55%.[Figure2,3]

• Telemetry:Multiplerunsofnon-sustainedventriculartachycardia- longestof5beats.

• CardiacCatheterization:Proximalleftanteriordescending(LAD)arterythrombuswith70%stenosisanddistalLADocclusion.Patientwastreatedwithunfractionatedheparinandglycoprotein2b/3ainhibitor(Tirofiban).[Figure4]

• Second Catheterization: Onthefollowingday,residualLADthrombuswasidentifiedwiththehelpofFractionalFlowReserveprocedure.Itwastreatedwithacombinationofintracoronarythrombolytic(Alteplase)andanaspirationthrombectomy.[Figure5]

• Hypercoagulabilitypaneldidnotrevealunderlyingpathologythatmayhavecontributedtothrombusformation.

• Patientwasultimatelydischargedonoralanticoagulation(Rivaroxaban)forthreemonths.

Figure4.InitialCardiacCatheterization

Figure2.TTEdepictingsystole

SelectedReferences1. Selcuk Oetal.VeryLateStentThrombosisinaPatientPresentingwithAcuteCarbonMonoxidePoisoning.JEmerg MedCaseRep2017;8:37-39.

2.Unlu Metal.Thrombolytictherapyinapatientwithinferolateralmyocardialinfarctionaftercarbonmonoxidepoisoning.SageJournals2015.

3.MarilouCCetal.Intracoronarythrombusformationfollowingcarbonmonoxidepoisoning.JForensicSciences2017;

4. Dziewierz Aetal.PrimaryangioplastyinpatientwithST-segmentelevationmyocardialinfarctioninthesettingofintentionalcarbonmonoxidepoisoning.JEmerg Med2013;45(6)831-834.

5. Soohyun Ketal.AcaseofacutecarbonmonoxidepoisoningresultinginanSTelevationmyocardialinfarction.KoreanCirc J2012;42(2)133-135.

6.Gonullu Hetal.STelevationmyocardialinfarctionduetocarbonmonoxidepoisoning.EurasianJMed2011;43(2):125-128.

7.Marius-NunezA.Myocardialinfarctionwithnormalcoronaryarteriesafteracuteexposuretocarbonmonoxide.Chest1990;97(2);491-494.

8. Satran etal.Cardiovascularmanifestationsofmoderatetoseverecarbonmonoxidepoisoning.JAmCollCardiology2005;45(9);1513-1516.

9.GandiniCetal.Carbonmonoxidecardiotoxicity.JToxicol Clin Toxicol 2001;39:35-44.

Figure7LADThrombusInterventions

Number Percent

BalloonAngioplasty 3 37.5%

NotTreated 1 12.5%

DrugElutingStent 1 12.5%

HyperbaricOxygenChamber 1 12.5%

SystemicThrombolytic 1 12.5%

CombinationofGlycoprotein2b/3ainhibitor,Intracoronarythrombolytic,AspirationThrombectomy

1 12.5%

Total 8 100%

Figure3.TTEdepictingdiastole

Figure5.SecondLookCardiacCatheterization