CASE REPORT

Be smart, don't kick the heart

R.L. Braam, D.P. Hertzberger, B.T.J. Meursing, A.J.M. Oude Ophuis

Blunt chest trauma is a rare cause of cardiacpathology. Nevertheless, a variety oflife-threateningcardiac diseases can be caused by blunt chesttraumas. In this case report we describe a myo-cardial infarction associated with kickboxing. Wealso review the literature describing myocardialinfarction associated with blunt chest trauma.(NeHHeartJ2005;13:280-2.)

Keywords: blunt chest trauma, kickboxing, myocardialinfarction

Piye days before presentation, a 25-year-old manreceived several hard kicks on his sternum during

a kickboxing fight. Understandably he had chest painfor several hours.

In the early morning of the day he presented, heexperienced a squeezing pain located around his throatand radiating to his chest and left arm. He used tosmoke about 20 cigarettes a day and drank largeamounts of alcohol at the weekend. The patientadmitted to have used cocaine in the past, howevernot during the last three months.

Physical examination was normal, except for afourth heart sound. No pericardial friction rub washeard.

The electrocardiogram showed signs of a recentanterolateral myocardial infarction (figure 1). The chestX-ray showed a slightly enlarged heart but noabnormalities in the lung fields and shape of themediastinum. Laboratory measurements on admission

R.L. BraamSt. Antonius Hospital, NieuwegeinD.P. Hertzb.rgerB.TJ. MeumingAJ.M. Oude OphulsCanisius-Wilhelmina Hospital, Nymegen

Correspondence to: A.J.M. Oude OphuisDepartment of Cardiology, Canisius-Wilhelmina Hospital,PO Box 9015, 6500 GS NijmegenE-mail: ton@oude.ophuis.net

showed an elevated creatinine kinase level (877 U/1,normal value <200 U/1), a normal aspartate amino-transferase of 37 U/A and an elevated level of lactatedehydrogenase (LDH) of561 U/1. Over the next fewdays these values normalised. Troponin-T at admissionwas elevated at 0.41 gg/l.

Treatment with acetylsalicylic acid, captopril andintravenous heparin was started. During mobilisationno new chest pain occurred. Nine days after thetrauma, coronary angiography was performed. Fixedstenoses as seen in coronary artery disease were notvisible (figures 2 and 3). Left ventriculography,however, showed dyskinesia ofthe apex (figure 4).

The fasting cholesterol level was 4.7 mmol/lwithout treatment. Antithrombin III level was notlowered and testing for hyperhomocysteinaemia wasnegative.

DiscussionLDH, troponin-T, electrocardiogram and left ven-tricular angiography showed that this young male hadsuffered a myocardial infarction.

The position ofthe heart between the sternum andthe vertebral column makes it vulnerable for injuryfrom nonpenetrating chest trauma."2 Blunt chesttrauma can lead to several cardiac injuries: myocardialcontusion, arrhythmias, valvular damage, ventricularfree wall rupture, ventricular septal rupture andcoronary artery occlusion with myocardial infarction.3

The incidence of nonpenetrating traumatic injury tothe heart in the presence ofsevere trauma reported inautopsy and clinical series varies widely.5 Myocardialinfarction after a blunt chest trauma has been reportedseveral times before.'-46-'8 Using Medline 70 casesreported between 1940 and 2002 could be identified(data available on request). Ofthese 70 cases, 34 weredue to traffic accidents and 23 cases were associatedwith sporting activities, such as softball, boxing, cricket,horseback riding, soccer, rugby, (water)skiing andbasketball. The mean age ofthe 70 subjects was 33±12years. Females were less often (n=10) involved than men.Nowadays kickboxing is a popular sport. During akickbox fight opponents sustain high-energy blows,

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Be smart, don't kick the heart

Figure 1. Ekctrocardiogram on presentation, with signs ofrecent anterolateral myocardial infarction.

leading to frequent acceleration-deceleration traumas.Using a dummy model it was shown that kicks andpunches during kickboxing can produce violentacceleration of90 to 100 G when aimed at the head.Kicks aimed lower down are even more powerful.'9

Coronary artery occlusion after blunt chest traumais usually secondary to intimal tears, subintimalhaemorrhage, acute thrombosis or disruption ofatheromatous plaque.'7'20 In 65 of the 70 identifiedcases autopsy or angiography was performed todocument coronary artery abnormalities. In 11 ofthese

Figure 2. Right coronary artery, without any abnormalities.

65 cases normal coronary arteries were found. One ofthese patients was treated with thrombolysis prior toangiography. An angiographic picture or autopsyfindings suggestive of thrombus were found in 12patients. Intimal dissection was seen in 18 patients.

Intimal tearing after blunt chest trauma is probablythe result of direct injury from compression of theanterior chest wall and shear forces in the anterior wallgenerated by sudden deceleration during impact.2'Most, i.e. 47 of70 cases ofmyocardial infarction, werelocated anteriorly.

Figure 3. Left coronary artety, without any abnormalities.

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Be smart, don't kick the heart

Figure 4. Leftventricularangiogram in RAOprojction, showingslight dykincsis ofapex.

In our case, there is a strong association between therecent symptoms from the patient's hard kickboxingfight five days before admission and his recentmyocardial infarction on admission. Our patient wastreated medically. Angioplasty and thrombolysis in theacute stage of myocardial infarction associated withblunt trauma have been described. Frequentlythrombolysis is not considered an option because oftheassociated trauma. Jessurun22 showed by angioscopythat occlusion with a red thrombus was the cause ofmyocardial infarction in a patient hit by a ball duringa soccer game. Five of 70 patients were treated withangioplasty, five patients received thrombolysis (threesystemic, two intracoronary).

In our opinion, the long-term treatment of thispatient should consist ofacetylsalicylic acid and an ACEinhibitor. Fosinopril was started because of the dys-kinesia of the apex present on the left ventricularangiogram. Whether treatment with a statin shouldbe given is in our opinion debatable.

Acute myocardial infarction after blunt chest traumais rare butwhen left unrecognised is accompanied withconsiderable morbidity and mortality in youngpatients. A high index of suspicion and electro-cardiography is usually sufficient to come to the correctdiagnosis. In the acute stage, PCI or thrombolysis (if

considered safe in the face of concomitant trauma)should be considered. A

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