International Journal of Cardiology 180 (2015) 214–215
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Acute myocardial infarction and acute stroke: Between a rock and a hard place Vassilios Vassiliou a,⁎, Bushra Rana b, Martin Goddard c, Denise Braganza b a b c
CMR Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK Department of Cardiology, Papworth Hospital, Cambridge, CB23 3RE, United Kingdom Department of Pathology, Papworth Hospital, Cambridge, CB23 3RE, United Kingdom
a r t i c l e
i n f o
Article history: Received 20 October 2014 Accepted 21 October 2014 Available online 22 October 2014 Keywords: Acute myocardial infarction Stroke Ulcerated plaque Thrombus embolization
A 53 year-old woman developed severe chest pain, breathlessness and palpitations whilst being told some very devastating news. As the symptoms persisted for more than 15 min, electrocardiography was undertaken in the community confirming an anterolateral STEMI. Following the electrocardiographic findings the patient was loaded orally in the community with aspirin 300 mg and clopidogrel 600 mg and was urgently transferred via the community activation primary PCI route to our institution for emergency coronary angiography. On arrival we noted new decreased consciousness and an evolving dense right hemiplegia with dysphasia. Further decrease in her conscious level necessitated tracheal intubation and ventilation for airway protection. Emergency CT head confirmed a large left middle cerebral artery (MCA) ischemic stroke with no hemorrhage or midline shift. Thrombolysis was considered to treat both pathologies (acute myocardial infarction and acute ischemic stroke) but deemed contraindicated by the neurologists in view of the decreased consciousness. Immediately after the CT we proceeded to emergency coronary angiography. An ostial occlusion of the LAD was seen (Fig. 1A, Online video 1) with TIMI 3 flow restored following prolific thrombus aspiration and intravenous GTN (Fig. 1B, Online video 2). Following the thrombus aspiration the coronary appeared smooth and no identifiable lesions were seen
⁎ Corresponding author. E-mail address: [email protected] (V. Vassiliou).
http://dx.doi.org/10.1016/j.ijcard.2014.10.101 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
requiring percutaneous stenting. The non-culprit right coronary artery was dominant and unobstructed. Given the smooth nature of the LAD a coronary embolus was suspected. She was transferred to the intensive care and transesophageal echocardiography ruled out LV thrombus or shunts/PFO but showed a mass superior to the left coronary sinus (Fig. 1C and online video 3). After a few hours, deteriorating neurology prompted repeat CT head revealing midline shift and significant bilateral strokes consistent with embolism (Fig. 1D). Further escalation of therapy was felt inappropriate and the patient died a few hours later. At autopsy an ulcerated plaque comprising of fragmented fibrin/thrombus above the left coronary sinus was noted with no evidence of aortic dissection (Fig. 1E, F). We postulate that the plaque developed as a result of a transient hypertensive crisis in response to the bad news that the patient received, and that the hypertensive crisis led to a procoagulant state [1]. The plaque then transiently occluded the ostium of Left Main Coronary Artery leading to intracoronary thrombus formation which subsequently embolized to the brain with tragic consequences. Although acute stroke in the context of an acute myocardial infarction is usually secondary to embolization of LV myocardial thrombus, as this case demonstrates other unusual pathologies can predispose to simultaneous myocardial infarction and stroke. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.10.101. Conflicts of interest None. Reference [1] B.J. Van den Born, E.C. Lowenberg, N.V. van der Hoeven, B. de Laat, J.C. Meijers, M. Levi, G.A. van Montfrans, Endothelial dysfunction, platelet activation, thrombogenesis and fibrinolysis in patients in hypertensive crisis, J. Hypertens. 29 (5) (2011) 922–927.
V. Vassiliou et al. / International Journal of Cardiology 180 (2015) 214–215
215
Fig. 1. (A) Coronary angiography showing ostial occlusion of the LAD, (B) coronary angiography showing TIMI 3 flow in the LAD following prolific thrombus aspiration, with smooth coronary wall and no lesion warranting intervention, (C) 3D TEE localizing the mass (arrow) superior to the origin of the left coronary ostium and the left main coronary artery — review of panel (A) can show the mass present at above the left ostium during angiography, (D) CT head showing bilateral ischemic stokes and significant midline shift, (E) macroscopic and (F) microscopic appearances of the unusual plaque (white arrows) located superior to the origin of the left coronary ostium (yellow arrow) and left main coronary artery.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Acute myocardial infarction and acute stroke: Between a rock and a hard place Vassilios Vassiliou a,⁎, Bushra Rana b, Martin Goddard c, Denise Braganza b a b c
CMR Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK Department of Cardiology, Papworth Hospital, Cambridge, CB23 3RE, United Kingdom Department of Pathology, Papworth Hospital, Cambridge, CB23 3RE, United Kingdom
a r t i c l e
i n f o
Article history: Received 20 October 2014 Accepted 21 October 2014 Available online 22 October 2014 Keywords: Acute myocardial infarction Stroke Ulcerated plaque Thrombus embolization
A 53 year-old woman developed severe chest pain, breathlessness and palpitations whilst being told some very devastating news. As the symptoms persisted for more than 15 min, electrocardiography was undertaken in the community confirming an anterolateral STEMI. Following the electrocardiographic findings the patient was loaded orally in the community with aspirin 300 mg and clopidogrel 600 mg and was urgently transferred via the community activation primary PCI route to our institution for emergency coronary angiography. On arrival we noted new decreased consciousness and an evolving dense right hemiplegia with dysphasia. Further decrease in her conscious level necessitated tracheal intubation and ventilation for airway protection. Emergency CT head confirmed a large left middle cerebral artery (MCA) ischemic stroke with no hemorrhage or midline shift. Thrombolysis was considered to treat both pathologies (acute myocardial infarction and acute ischemic stroke) but deemed contraindicated by the neurologists in view of the decreased consciousness. Immediately after the CT we proceeded to emergency coronary angiography. An ostial occlusion of the LAD was seen (Fig. 1A, Online video 1) with TIMI 3 flow restored following prolific thrombus aspiration and intravenous GTN (Fig. 1B, Online video 2). Following the thrombus aspiration the coronary appeared smooth and no identifiable lesions were seen
⁎ Corresponding author. E-mail address: [email protected] (V. Vassiliou).
http://dx.doi.org/10.1016/j.ijcard.2014.10.101 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
requiring percutaneous stenting. The non-culprit right coronary artery was dominant and unobstructed. Given the smooth nature of the LAD a coronary embolus was suspected. She was transferred to the intensive care and transesophageal echocardiography ruled out LV thrombus or shunts/PFO but showed a mass superior to the left coronary sinus (Fig. 1C and online video 3). After a few hours, deteriorating neurology prompted repeat CT head revealing midline shift and significant bilateral strokes consistent with embolism (Fig. 1D). Further escalation of therapy was felt inappropriate and the patient died a few hours later. At autopsy an ulcerated plaque comprising of fragmented fibrin/thrombus above the left coronary sinus was noted with no evidence of aortic dissection (Fig. 1E, F). We postulate that the plaque developed as a result of a transient hypertensive crisis in response to the bad news that the patient received, and that the hypertensive crisis led to a procoagulant state [1]. The plaque then transiently occluded the ostium of Left Main Coronary Artery leading to intracoronary thrombus formation which subsequently embolized to the brain with tragic consequences. Although acute stroke in the context of an acute myocardial infarction is usually secondary to embolization of LV myocardial thrombus, as this case demonstrates other unusual pathologies can predispose to simultaneous myocardial infarction and stroke. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.10.101. Conflicts of interest None. Reference [1] B.J. Van den Born, E.C. Lowenberg, N.V. van der Hoeven, B. de Laat, J.C. Meijers, M. Levi, G.A. van Montfrans, Endothelial dysfunction, platelet activation, thrombogenesis and fibrinolysis in patients in hypertensive crisis, J. Hypertens. 29 (5) (2011) 922–927.
V. Vassiliou et al. / International Journal of Cardiology 180 (2015) 214–215
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Fig. 1. (A) Coronary angiography showing ostial occlusion of the LAD, (B) coronary angiography showing TIMI 3 flow in the LAD following prolific thrombus aspiration, with smooth coronary wall and no lesion warranting intervention, (C) 3D TEE localizing the mass (arrow) superior to the origin of the left coronary ostium and the left main coronary artery — review of panel (A) can show the mass present at above the left ostium during angiography, (D) CT head showing bilateral ischemic stokes and significant midline shift, (E) macroscopic and (F) microscopic appearances of the unusual plaque (white arrows) located superior to the origin of the left coronary ostium (yellow arrow) and left main coronary artery.
