Various mechanisms of myocardial necrosis development due to combat injury as a reason for discussion: a case series

Abstract

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.