Introduction: Acute myocardial infarction (AMI) is a rare but often lethal consequence of a blunt cardiac trauma. Falls leading to coronary artery dissections are rare, thus underlining the lack of experience in their management.
Case report description: a 55-year-old male patient with type 2 diabetes and no relevant past medical history was admitted to our hospital facility after a 30-meter fall during rock-climbing. On arrival, he was hemodynamically and neurologically stable. He underwent a full trauma evaluation: multiple facial bones fractures were diagnosed. An electrocardiogram revealed a QS morphology of the QRS and ST elevation in the precordial lead from V1 to V3 with reciprocal ST depression in the inferior leads. High sensitivity (hs) Troponin T was slightly elevated (49 ng/L, normal values <14 ng/L). A cardiac ultrasound documented a left ventricular dysfunction (LVEF 40%) with akinesia of mid-apical antero-septal and anterior walls. Biomarkers further increased with Troponin reaching 199 ng/L and creatinine phosphokinase-MB 24,7 ug/L (normal value <5 ug/L). Coronary angiography demonstrated proximal occlusion of the left anterior descending (LAD) coronary artery with an image consistent with traumatic coronary artery dissection, confirmed by a cardiac CT scan showing the proximal occlusion of the LAD with retrograde perfusion of its downstream portion. Considering the left ventricular dysfunction, the elevation of cardiac biomarkers (peak CK-MB 187 ug/L, peak hs troponin T 5400 ng/L) and the acceptable hemorrhagic risk in spite of the need for facial surgery, a coronary angioplasty was performed. A dual antiplatlet therapy with acetilsalicidic acid and clopidogrel began. Nine days later the patient underwent the maxillo-facial surgery: clopidogrel was stopped provisionally and a bridge strategy using tirofiban was chosen. Post-operatory was uneventful. A full recovery of cardiac function was assessed after one year (LVEF of 55%).
Discussion: Few cases of blunt cardiac trauma with coronary artery dissections have been reported and treated successfully, with the LAD being the most frequently involved vessel (76%). If urgent non-cardiac surgery can be postponed, a percutaneus revascularization eventually followed by tirofiban as bridge therapy can be suggested, carefully considering the risk of stent thrombosis and the hemorrhagic risk conveyed by the trauma itself.