Various mechanisms of myocardial necrosis development due to combat injury as a reason for discussion: a case series
Keywords:myocardial infarction, wounds and injuries, heart contusions, heart injuries, myocardial bridging
The real clinical practice of the last 8 years in Ukraine indicates the possibility of myocardial injury developing in wounded with combat trauma, including those meeting the criteria for myocardial infarction (predominantly type 2), which differs significantly in the mechanism of development, resulting in numerous difficulties for doctors in providing medical care to such patients (formulation of the diagnosis, choice of treatment tactics). The current recommendations of the European Society of Cardiology for the management of patients with acute coronary syndromes after the adoption of the Fourth Universal Definition of Myocardial Infarction do not consider special approaches to the treatment of patients with myocardial necrosis associated with trauma.
The aim of this publication was to demonstrate, using the example of a case series, the relevance of the problem of terminology, diagnosis, and treatment of myocardial infarction caused by a combat injury.
In all three clinical cases presented, young and middle-aged patients were diagnosed with myocardial infarction in accordance with the Fourth Universal Definition. In all these cases, there were no atherosclerotic coronary artery lesions, and a type 2 myocardial infarction was assumed due to acute myocardial ischemia as a consequence of the injured coronary artery ligation (case 1); microcirculation disorders in the area of myocardial contusion (case 2); anatomical feature of the coronary artery in the form of its intramural course in the presence of severe sympathicotonia and sinus tachycardia (case 3). Because all three patients had myocardial necrosis associated with trauma of the chest and heart, the question arose of the preference for coding such pathology through ICD-10 as section S00-T88 (injury, poisoning and certain other consequences of external causes), namely S26 (injury of heart), but not as I21 (acute myocardial infarction) from the section I00-I99 (diseases of the circulatory system). Thus, the developed pathology in such patients will be clearly associated with the combat trauma, and their treatment will not be tied to the current Ukrainian Unified Protocol for the Management of Patients with ST-segment Elevation Acute Coronary Syndrome.
Conclusions. The presented clinical cases substantiate the planning of clinical trials and the development of recommendations for the management of patients with acute myocardial injury (including myocardial necrosis) and trauma of the heart and coronary arteries, depending on the mechanism of damage development.
Sydorova, N. M., Druz, O. V., Savytskyi, V. L., Chernenko, I. A., & Sydorova, L. L. (2022). Primary and secondary prevention of cardiovascular pathology in injured with combat trauma. Svit medytsyny ta biolohii-World of Medicine and Biology, 1(79), 130-134. https://doi.org/10.26724/2079-8334-2022-1-79-130-134
Khomenko, I. P., Korol, S. O., Khalik, S. V., Shapovalov, V. Yu., Yenin, R. V., Herasymenko, O. S., & Tertyshny, S. V. (2020). Klinichno-epidemiolohichnyi analiz struktury boiovoi khirurhichnoi travmy pry provedenni antyterorystychnoi operatsii / operatsii Obiednanykh syl na Skhodi Ukrainy [Clinical and epidemiological analysis of the structure of combat surgical trauma during the anti-terrorist operation / Joint Forces operation in Eastern Ukraine]. Ukrainskyi zhurnal viiskovoi medytsyny - Ukrainian Journal of Military Medicine, 2(2), 5-13. [in Ukrainian]. https://doi.org/10.46847/ujmm.2021.2(2)-005
Rating the severity of tissue damage. I. The abbreviated scale. (1971). JAMA, 215(2), 277-280. https://doi.org/10.1001/jama.1971.03180150059012
Moore, E. E., Malangoni, M. A., Cogbill, T. H., Shackford, S. R., Champion, H. R., Jurkovich, G. J., McAninch, J. W., & Trafton, P. G. (1994). Organ injury scaling. IV: Thoracic vascular, lung, cardiac, and diaphragm. The Journal of trauma, 36(3), 299-300.
RuDusky, B. M. (2007). Classification of myocardial contusion and blunt cardiac trauma. Angiology, 58(5), 610-613. https://doi.org/10.1177/0003319707305687
Ellis, S. G., Ajluni, S., Arnold, A. Z., Popma, J. J., Bittl, J. A., Eigler, N. L., Cowley, M. J., Raymond, R. E., Safian, R. D., & Whitlow, P. L. (1994). Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation, 90(6), 2725-2730. https://doi.org/10.1161/01.cir.90.6.2725
Huriev, S. O., Fil, A. Yu., & Hrytsyna, I. V. (2015). Patomorfolohichni zminy vnutrishnikh orhaniv u zahyblykh vnaslidok politravmy zi skeletnym komponentom poshkodzhennia [Pathomorphological changes of internal organs in victims of polytrauma with a skeletal component of damage]. Travma, (5), 5-10. [in Ukrainian].
Brodsky, S. V., Roh, L., Ashar, K., Braun, A., & Ramaswamy, G. (2008). Myocardial bridging of coronary arteries: A risk factor for myocardial fibrosis? International Journal of Cardiology, 124(3), 391-392. https://doi.org/10.1016/j.ijcard.2006.12.062
Ministry of Health of Ukraine. (2021, September 21). Unifikovanyi klinichnyi protokol ekstrenoi, pervynnoi, vtorynnoi (spetsializovanoi), tretynnoi (vysokospetsializovanoi) medychnoi dopomohy ta kardioreabilitatsii "Hostryi koronarnyi syndrom z elevatsiieiu sehmenta ST" [Unified clinical protocol of emergency, primary, secondary (specialized), tertiary (highly specialized) medical care and cardiorehabilitation "Acute coronary syndrome with ST segment elevation" (No. 1936)]. [in Ukrainian]. https://www.dec.gov.ua/wp-content/uploads/2021/09/2021_1936_ykpmd_gkszelev.pdf
Ibanez, B., James, S., Agewall, S., Antunes, M. J., Bucciarelli-Ducci, C., Bueno, H., Caforio, A., Crea, F., Goudevenos, J. A., Halvorsen, S., Hindricks, G., Kastrati, A., Lenzen, M. J., Prescott, E., Roffi, M., Valgimigli, M., Varenhorst, C., Vranckx, P., Widimský, P., & ESC Scientific Document Group (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). European heart journal, 39(2), 119-177. https://doi.org/10.1093/eurheartj/ehx393
Guzik, T. J., Mohiddin, S. A., Dimarco, A., Patel, V., Savvatis, K., Marelli-Berg, F. M., Madhur, M. S., Tomaszewski, M., Maffia, P., D'Acquisto, F., Nicklin, S. A., Marian, A. J., Nosalski, R., Murray, E. C., Guzik, B., Berry, C., Touyz, R. M., Kreutz, R., Wang, D. W., Bhella, D., … McInnes, I. B. (2020). COVID-19 and the cardiovascular system: implications for risk assessment, diagnosis, and treatment options. Cardiovascular research, 116(10), 1666-1687. https://doi.org/10.1093/cvr/cvaa106
Task Force for the management of COVID-19 of the European Society of Cardiology (2022). European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1-epidemiology, pathophysiology, and diagnosis. European heart journal, 43(11), 1033-1058. https://doi.org/10.1093/eurheartj/ehab696
Donkol, R. H.,& Saad, Z. (2013). Myocardial bridging analysis by coronary computed tomographic angiography in a Saudi population. World Journal of Cardiology, 5(11), 434-441. http://dx.doi.org/10.4330/wjc.v5.i11.434
Hostiuc, S., Negoi, I., Rusu, M. C., & Hostiuc, M. (2018). Myocardial Bridging: A Meta-Analysis of Prevalence. Journal of Forensic Sciences, 63(4), 1176-1185. https://doi.org/10.1111/1556-4029.13665
Roberts, W., Charles, S. M., Ang, C., Holda, M. K., Walocha, J., Lachman, N., Tubbs, R. S., & Loukas, M. (2021). Myocardial bridges: A meta-analysis. Clinical anatomy, 34(5), 685-709. https://doi.org/10.1002/ca.23697
Tsujita, K., Maehara, A., Mintz, G. S., Doi, H., Kubo, T., Castellanos, C., Liu, J., Yang, J., Oviedo, C., Franklin-Bond, T., Dasgupta, N., Biro, S., Dani, L., Dangas, G. D., Mehran, R., Kirtane, A. J., Lansky, A. J., Kreps, E. M., Collins, M. B., Stone, G. W., … Leon, M. B. (2008). Comparison of angiographic and intravascular ultrasonic detection of myocardial bridging of the left anterior descending coronary artery. The American journal of cardiology, 102(12), 1608-1613. https://doi.org/10.1016/j.amjcard.2008.07.054
Watanabe, Y., Arakawa, T., Kageyama, I., Aizawa, Y., Kumaki, K., Miki, A., & Terashima, T. (2016). Gross anatomical study on the human myocardial bridges with special reference to the spatial relationship among coronary arteries, cardiac veins, and autonomic nerves. Clinical anatomy, 29(3), 333-341. https://doi.org/10.1002/ca.22662
Rubinshtein, R., Gaspar, T., Lewis, B. S., Prasad, A., Peled, N., & Halon, D. A. (2013). Long-term prognosis and outcome in patients with a chest pain syndrome and myocardial bridging: a 64-slice coronary computed tomography angiography study. European Heart Journal - Cardiovascular Imaging, 14(6), 579-585. https://doi.org/10.1093/ehjci/jet010
Sternheim, D., Power, D. A., Samtani, R., Kini, A., Fuster, V., & Sharma, S. (2021). Myocardial Bridging: Diagnosis, Functional Assessment, and Management: JACC State-of-the-Art Review. Journal of the American College of Cardiology, 78(22), 2196-2212. https://doi.org/10.1016/j.jacc.2021.09.859
Gould, K. L., & Johnson, N. P. Myocardial Bridges: Lessons in Clinical Coronary Pathophysiology. (2015). JACC. Cardiovascular imaging, 8(6), 705-709. https://doi.org/10.1016/j.jcmg.2015.02.013
Sara, J. D. S., Corban, M. T., Prasad, M., Prasad, A., Gulati, R., Lerman, L. O., & Lerman, A. (2020). Prevalence of myocardial bridging associated with coronary endothelial dysfunction in patients with chest pain and non-obstructive coronary artery disease. EuroIntervention, 15(14), 1262-1268. https://doi.org/10.4244/EIJ-D-18-00920
Baxter, B. T., Moore, E. E., Moore, F. A., McCroskey, B. L. & Ammons, L. A. (1989). A plea for sensible management of myocardial contusion. American Journal of Surgery, 158(6), 557-561. https://doi.org/10.1016/0002-9610(89)90192-x
Van Lieshout, E. M. M., Verhofstad, M. H. J., Van Silfhout, D. J. T., & Dubois, E. A. (2021). Diagnostic approach for myocardial contusion: a retrospective evaluation of patient data and review of the literature. European Journal of Trauma and Emergency Surgery, 47(4), 259-1272. https://doi.org/10.1007/s00068-020-01305-4
Thygesen, Kr., Alpert, J. S., Allan, S. J., Bernard, R. Ch., Jeroen, J. B., Morrow, D. A., White, H. D. & ESC Scientific Document Group. (2019). Fourth universal definition of myocardial infarction 2018. European Heart Journal, 40( 3), 237-269. https://doi.org/10.1093/eurheartj/ehy462
Thygesen, K. (2019). 'Ten Commandments' for the Fourth Universal Definition of Myocardial Infarction 2018. European heart journal, 40(3), 226. https://doi.org/10.1093/eurheartj/ehy856
Sydorova, N. M., Peshkova, M. I., Voronko, A. A., Khomenko, I. V., & Tretiak, D. D. (2020). Rozrakhunok ryzyku rozvytku sertsevo-sudynnoi patolohii, shcho maie tryvalyi perebih, u postrazhdaloho z boiovoiu travmoiu: klinichnyi vypadok [Calculation of the risk of developing cardiovascular pathology with a long course in a victim of combat trauma: a clinical case]. World Science, 1(2), 35-42. [in Ukrainian]. https://doi.org/10.31435/rsglobal_ws/28022020/6928
How to Cite
LicenseAuthors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access)