Syncope, ST-Elevation Myocardial Infarction (STEMI), or Trauma? Blunt Coronary Bypass Graft Rupture in the Emergency...

Syncope is a frequent presentation to the emergency department and may result in secondary trauma such as falls. Cardiac syncope carries high morbidity and mortality, while blunt thoracic trauma may also lead to a wide spectrum of cardiac injuries, particularly in patients with prior cardiovascular surgery. Blunt thoracic trauma may present with chest pain, dyspnea, and hemodynamic instability. These clinical features closely resemble those of acute coronary syndromes. Electrocardiographic findings such as ST-segment elevation may indicate either primary acute coronary ischemia or myocardial involvement resulting from blunt cardiac injury. Differentiating between cardiac syncope with acute coronary syndrome and trauma-related cardiac injury can therefore be extremely challenging for emergency physicians.

A 64-year-old man with a history of coronary artery bypass grafting (CABG) and mitral valve replacement presented after a three-meter fall preceded by exertional syncope. On arrival, he reported chest pain, and an electrocardiogram (ECG) revealed ST-segment elevation in the lateral leads. An extended focused assessment with sonography in trauma (E-FAST) demonstrated a left-sided hemothorax. Computed tomography angiography (CTA) identified a large mediastinal hematoma with active extravasation from the left internal mammary artery-left anterior descending artery (LIMA-LAD) graft, distal occlusion of the graft, and compression-induced stenosis of the aorta-obtuse marginal (Ao-OM) saphenous vein graft. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This is, to our knowledge, the first reported case of traumatic rupture of a coronary bypass graft. Emergency physicians should recognize this rare but fatal complication, which can be distinguished from primary cardiac syncope through appropriate multimodal emergency evaluation and imaging.