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More Martial than Arts: Coronary Artery Dissection after Chest Kick

(A) Twelve-lead electrocardiogram showing ST-segment elevations >2 mm in inferolateral leads caused by dissection of the distal portion of a so-called wraparound left anterior descending artery. (B) Thrombotic occlusion of the proximal left anterior descending artery, which was treated with simple angioplasty and intracoronary administration of abciximab with final Thrombolysis In Myocardial Infarction (TIMI) 1 flow. (C) Intravascular ultrasound with evidence of intramural hematoma (solid arrow), left anterior descending artery dissection (dotted arrow), and (D) control coronary angiography after 48 hours with final TIMI 3 flow.

A 40-year-old male smoker without relevant medical history reported to the Emergency Department 2 days after a kick to his unprotected chest during a karate training session. The day before, he had presented with severe chest pain and his general practitioner had prescribed ibuprofen. No electrocardiogram (ECG) had been done. At the Emergency Department, the patient complained of severe chest pain with breathing or touching the left hemithorax. Vital signs and physical exploration were normal. The 12-lead ECG showed ST-segment elevation in the inferolateral leads (II, III, aVF, V4-V6Figure, A). Transthoracic echocardiography showed preserved left ventricular ejection fraction with apical hypokinesia and no pericardial effusion. Aortic dissection was ruled out by contrast-enhanced computed tomography. Peak troponin I was 18.4 ng/mL (reference <0.050 ng/mL). The patient was transferred for coronary angiography, which showed an image suggestive of ulcerated plaque in the proximal left anterior descending artery and thrombotic occlusion of the distal left anterior descending artery. Balloon angioplasty was performed in the distal left anterior descending artery with intracoronary administration of abciximab, obtaining a Thrombolysis In Myocardial Infarction (TIMI) 1 flow in the distal left anterior descending artery without significant stenosis in the proximal segment. Forty-eight hours later a control coronary angiography and intravascular ultrasound confirmed the absence of significant stenosis in the left anterior descending artery with TIMI3 flow and provided evidence of dissection in the proximal segment with intraluminal thrombus and intramural hematoma (Figure, B-D). No intervention was necessary. The patient was discharged on double antiplatelet and statin therapy after 7 days free of cardiac symptoms.

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-Markus Linhart, MDa,b, Walter Bragagnini, MDa, Ander Regueiro, MDb, Eduardo Flores, MDb, Guiomar Mendieta, MDb, Antonio Martínez-Rubio, MD, PhDa

This article originally appeared in the May 2019 issue of The American Journal of Medicine.

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