Download ST - segment Elevation Myocardial Infarction complicating an

ST - segment Elevation Myocardial
Infarction complicating an atypical
Kawasaki disease
Raluca PRISECARU, Marc VINCENT, Steven VERCAUTEREN
Brussels Heart Center, Brussels, Belgium
Disclosure
None
Clinical case
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20 years old female for typical chest pain (<2h)
Aseptic meningoencephalitis 4 weeks ago
No risk factors for coronary artery disease
Absence of recent trauma/ contusion
Deny cocaine abuse/ contraceptive medication
Physical examination: normal BP and tachycardia
Clinical case
• ECG: anterior ST-elevation.
• Troponine level: 19.97 ng/ml (N:0 – 0.1 ng/ml)
• TTE:
- systolic dysfunction- LVEF at 40%
- antero septal akinesia
On the way to the Cathlab…
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Hematological disorders
Dissection of coronary artery
Coronary spasm
Tako Tsubo cardiomyopathy
Congenital abnormality of coronary arteries
Diseases involving intimal proliferation
Arteritis
occlusion at the
mid segment of
LAD
Stenosis at mid and
distal right coronary
artery (RCA).
Fusiforme coronary
aneurysms.
Coronary arteriography
• occlusion at the mid segment of LAD (left anterior
descending artery)
• non significant stenosis at proximal circumflex artery,
mid and distal right coronary artery
• multiple fusiforme coronary aneurysms with internal
diameter between 2-7 mm.
An intracoronary thrombus aspiration was
performed and the left anterior descending artery
was recanalized with restoration of a TIMI 2 flow
Coronary aneurysms
1. Congenital aneurisms
2. Acquired aneurisms
No RF for atherosclerosis
No trauma
No cocaine abuse
Vasculitis ??
Vasculitis?
- Polyarteritis nodosa
- Giant cell arteritis
- Takayasu arteritis
- Kawasaki disease
- Churg-Strauss syndrome
- Granulomatosis with polyangiitis (Wegener’s)
- Hypersensitivity vasculitis
- Henoch-Schönlein purpura
- Vasculitis secondary to connective tissue disorders
- Vasculitis secondary to viral infection…..
It’s time for a diagnosis…
The diagnosis of ST - segment Elevation
Myocardial Infarction complicating a
Kawasaki disease was established, based on:
- multiple aneurysms
- multiple stenosis
- aseptic meningo encephalitis
A 48 occlusion
LAD
h coronary
and dissection
arteriography:
occlusion of LAD
associated with
dissection
LAD occlusion
and dissection
Treatement: drug
eluting stent
placement.
A 48 h coronary
arteriography:
After drug eluting
stent placement.
She was discharged with the following
treatment prescription:
- long-term duble antiplatelet therapy with
aspirine and clopidogrel
- β-adrenergic–blocking drug
- ACE inhibitor
- statine.
After 1 month
• The patient was asymptomatic
• The ultrafast computed tomography (CT):
persistent aneurysmatic lesions on both
principal and secondary arteries.
• The ETT:
- persistent systolic dysfunction (LVEF at 40%) antero septal wall akinesia.
The Kawasaki disease
• Acute, small-to-medium-vessel vasculitis of
unknown etiology
• Preferentially affects children
• Meningitis may be in seldom cases a feature
of KD (subacute phase).
• No specific laboratory tests
Major clinical criterias
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Fever > 5 days
Bilateral conjunctivitis
Rash
Erythema of the lips and oral mucosa
Cervical lymphadenopathy.
Diagnosis in KD
• >=4/5 of main clinical criteria
• <4/5 of main clinical features + coronary
artery disease detected on angiography.
• <4/5 of main clinical features + coronary
artery disease detected on ETT
Cardiac complications of KD
• Coronary aneurysms leading to
- myocardial ischemia
- myocardial infarction
- sudden cardiac death
• Decreased myocardial contractility
• Coronary arteritis without aneurysms
• Mild valvular regurgitation
• Pericardial effusion
Coronary artery aneurysms
• Develop in 15% to 25% of children with
untreated KD
• Evolves during the subacute phase (D 10 to 40
after onset of fever) when dinamics and
mortality are highest
• Involve multiple vessels - proximal segments
and bifurcations
Extracardiac complications
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Peripheral arterial obstruction
Urinary abnormalities and renal disease
wide variety of gastrointestinal manifestations
Persistent sensorineural hearing loss
Behavioral changes
Prognosis
• Mortality rate of KD is low (0.1 to 0.3%)
• Low rate of recurrence for KD (commonly occurred
within the first 12 months after the initial episode of
KD )
• Long-term morbidity related to CA involvement:
– best prognosis: fusiform aneurysms <8 mm in diameter
(generally regresse over time )
– giant aneurysms - highest risk of morbidity and mortality
(thrombosis and stenoses at the proximal and/or distal
ends of the aneurysms).
Problems in management of KD
1. Onset of KD in adults:
- rare
- frequently atypical
2. The diagnosis presents more difficulties and
can easily be missed
3. Atypical forms of KD seem to predict a
higher risk to coronary abnormalities
Conclusion
• Major complication of KD: CA aneurysms
• Myocardial infarction- main cause of death in KD
• Although the incidence of acute myocardial
infarction in pediatric or young patients is low , the
diagnosis of KD should be considered as an
underlying cause.
Thank you!