Blunt trauma causing thrombotic occlusive myocardial infarction

Introduction: Traumatic myocardial infarction (TMI) is a rare but serious complication of blunt chest trauma, typically arising from coronary artery dissection, intramural hematoma, or myocardial contusion. Early recognition and intervention are critical, but diagnosis can be challenging given the broad differential for chest pain in trauma patients. Case presentation: A 66-year-old female presented to a quaternary academic emergency department after a motor vehicle collision with progressive chest pain. Initial electrocardiogram (ECG) showed hyperacute T-waves in lead III, ST depression with T-wave inversion in aVL, and ST depression in V2, with posterior leads revealing ST elevation in V7-V9. Trauma imaging ruled out aortic injury but revealed right coronary artery (RCA) occlusion. Left heart catheterization demonstrated complete occlusion of the mid-RCA, managed successfully with drug-eluting stent placement. The patient was discharged chest-pain free on hospital day four with plans for cardiac rehabilitation. Discussion: This case highlights a rare presentation of TMI in an older patient, with RCA involvement rather than the more common left anterior descending artery involvement. While TMI often occurs in patients under 45 and typically results from coronary dissection, the occlusion observed in this case is most consistent with intraluminal thrombosis, though this cannot be definitively determined. Diagnosing TMI requires maintaining a high index of suspicion, as symptoms may mimic myocardial contusion. Timely PCI is preferred over thrombolytics, given the potential for underlying coronary artery dissection. Conclusion: TMI, though rare, must be considered in trauma patients with chest pain and ischemic ECG changes. Early ECG acquisition and imaging are essential. PCI and CABG are the most common primary interventions, while thrombolytics should generally be avoided. Continued research is needed to refine diagnostic and management strategies for this complex condition.