International Journal of Cardiology 184 (2015) 653–654

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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard

Letter to the Editor

Acute myocardial infarction due to left anterior descending coronary artery dissection after rubber bullet shooting Antoine Noel ⁎, Philippe Castellant, Martine Gilard, Jacques Mansourati Department of Cardiology, CHU Brest, Hôpital La Cavale Blanche, Boulevard Tanguy Prigent, 29609 Brest Cedex, France

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Article history: Received 19 January 2015 Accepted 1 March 2015 Available online 4 March 2015 Keywords: Acute myocardial infarction Coronary artery dissection Rubber bullet shooting Less lethal weapon

A 43-year-old healthy farmer received an attenuated energy projectile (hard rubber bullet probably fired by Flashball®, Verney-Carron®, France) in the left hemithorax at a close distance range during a riot. He complained from a sudden and immediate retrosternal chest pain. The persistence of this pain led him to refer to his general physician the next day. A 12-lead electrocardiogram (ECG) showed a 2 mm ST segment elevation associated with Q waves in antero-septal leads. He was then referred to the Intensive Care Unit of Cardiology. He continued to complain of a persistent but decreasing angina-like chest pain. Physical examination showed a 5 cm diameter contusion over the left anterior chest wall coherent with hard rubber bullet shot (Fig. 1A). ECG showed signs of subacute antero-septal myocardial infarction (Fig. 1B). Biological tests drawn on arrival (about 24 h after gunshot) showed a significant elevation in troponin I of 5.28 ng/mL (normal b 0.1 ng/mL) and a creatine kinase of 547 UI/L (normal 32–294 ng/mL). The values of fasting glucose, cholesterol and triglycerides were within normal limits. His only risk factor for coronary artery disease was smoking but interrupted 5 years earlier. Chest X-ray was normal with particularly no rib fracture. Transthoracic echocardiogram (TTE) performed on the same day showed severe hypokinesia of apical wall. Left ventricular ejection fraction was 55%. No pericardial effusion and no valvular abnormality were present. ⁎ Corresponding author. E-mail addresses: [email protected] (A. Noel), [email protected] (P. Castellant), [email protected] (M. Gilard), [email protected] (J. Mansourati).

http://dx.doi.org/10.1016/j.ijcard.2015.03.014 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.

Based on ECG, TTE and troponin I findings, the diagnosis of subacute ST elevation myocardial infarction of the left anterior descending artery was established. Coronary angiography was performed 24 h after admission and showed an abrupt and eccentric spiral dissection of the distal left anterior descending (LAD) artery with normal antegrade filling. The other coronary arteries were normal (Fig. 2). This traumatic coronary artery dissection was treated conservatively with heparin stopped before release, aspirin and clopidogrel for one month. The patient has been followed closely and remained stable without symptoms of ischemia. ECG at 3 months was normal and stress myocardial scintigraphy with 99mTc found no ischemia. We report the first case of acute myocardial infarction due to LAD coronary artery dissection after rubber bullet shooting. The patient had no signs of significant preexisting coronary artery stenosis and the onset of symptoms suggests a causal relation. Coronary artery traumatic lesion often occurs in young men in relation with car and sport accidents (56% and 32%) [1]. Specific management in Intensive Care Unit of Cardiology is often delayed because of atypical presentation such as palpation induced chest pain. Moreover, cardiac injury is suspected in patients with chest pain after trauma from 12-lead ECG signs and bedside echography showing segmental ventricular dyskinesia. Diagnosis is based on coronary angiography findings. However MRI, OCT and CT scan can be considered. Early diagnosis and management of this injury are important to minimize myocardial damage and reduce mortality. LAD is frequently concerned (56.9%) because of its proximity to the chest wall, by dissection (38%) but coronary arteries can be angiographically normal thanks to spontaneous thrombolysis or spasm with transitory occlusion. The mechanism of injury is thought to be shearing of the coronary vessel wall, causing intimal tearing. Therefore thoracic bone trauma appears to be protective for myocardial lesions [2]. Treatment is most often conservative (51%) but remains controversial with coronary artery bypass grafting or angioplasty; fibrinolysis is often postponed due to recent trauma. Repeated coronary angiograms in several patients with occlusions caused by blunt chest cardiac injury have demonstrated that the natural history of these lesions looks like intimal injuries after cardiac catheterization with complete healing of the lesions within 6 months [3]. Non-lethal low-velocity weapons, like Flashball® (Verney-Carron®, France) are increasingly used, even by the local police to incapacitate combative individuals and to disperse riot crowds. This gun fires large

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A. Noel et al. / International Journal of Cardiology 184 (2015) 653–654

Fig. 1A. Contusion over the left anterior chest wall coherent with hard rubber bullet shot. Fig. 2A: 12-lead ECG demostrating a subacute antero-septal myocardial infarction.

Fig. 1B. Angiogram demonstrating a type A dissection (NHLBI classification) of the distal left anterior descending artery with normal antegrade filling.

rubber bullets, avoiding use of firearms. This case highlights the fact that such attenuated energy projectile can cause significant and life-threatening injury. Conflict of interest statement The authors report no relationships that could be construed as a conflict of interest. Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.03.014.

References [1] E. Brasseur, A. Ghuysen, V. Mommens, N. Janssen, V. Legrand, V. D'Orio, Dissection coronaire et traumatisme fermé, Ann. Cardiol. Angéiol. 55 (2006) 233–239. [2] K. Lobay, C. MacGougan, Traumatic coronary artery dissection: a case report and literature review, J. Emerg. Med. 43 (2010) 239–243. [3] E. Ginzburg, J. Dygert, E. Parra-Davila, M. Lynn, J. Almeida, M. Mayor, Coronary artery stenting for occlusive dissection after blunt chest trauma, J. Trauma 45 (1998) 157–161.

Acute myocardial infarction due to left anterior descending coronary artery dissection after rubber bullet shooting.

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