Myocardial Infarction in Childhood Workup

  • Author: Louis I Bezold, MD; Chief Editor: Stuart Berger, MD   more...
 
Updated: Dec 5, 2011
 

Laboratory Studies

The following studies are indicated in pediatric patients with myocardial infarction:

  • Testing of cardiac enzymes is the criterion standard for identification of myocardial cell death by measuring the following levels:
    • Serum glutamic-oxaloacetic transaminase (SGOT)
    • Lactate dehydrogenase (LDH) and isoenzymes
    • Creatine kinase (CK)
    • CK-MB isoforms
    • Troponin I and troponin T
  • Levels of acute-phase reactants are elevated in the early stages of Kawasaki disease.
    • WBC
    • C-reactive protein
    • Erythrocyte sedimentation rate (ESR)
    • Thrombocytosis
    • α 1 -Antitrypsin (A1AT)

Evaluation for heritable forms of thrombophilia, such as prothrombin G20210 and C677T MTHFR gene mutations, and protein C deficiencies should be considered in young patients with myocardial ischemia.[9]

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Imaging Studies

  • Chest radiography: This is indicated to reveal cardiomegaly, with or without pulmonary venous congestion.
  • Echocardiography
    • Two-dimensional echocardiography may be used to identify the following:
      • The abnormal origin of the left coronary artery from the main pulmonary artery
      • Chamber enlargement
      • Systolic and diastolic dysfunction
      • Coronary artery ectasia or aneurysm
      • A flail mitral valve leaflet and ruptured papillary muscle
      • Segmental wall motion abnormality
      • Mural or intraventricular thrombi
    • In experienced hands, color-flow Doppler mapping can have the following uses:
      • Can be diagnostic for anomalous left coronary artery from the pulmonary artery (ALCAPA), demonstrating retrograde flow from the anomalous left coronary into the pulmonary trunk
      • Demonstrates direction of coronary artery flow
      • Quantifies mitral insufficiency
      • In conjunction with spectral Doppler, quantifies pulmonary hypertension
    • Tissue Doppler imaging (TDI): TDI is an echocardiographic technique that can noninvasively evaluate myocardial contraction and relaxation. Data suggest that TDI may have a role in early detection of graft failure due to coronary vasculopathy in orthotopic transplant recipients.[10]
  • CT and MRI
    • Multislice CT angiography has been shown to be useful in identifying coronary ostial or arterial stenoses in pediatric patients following the arterial switch operation for dextro-transposition of the great arteries (D-TGA).
    • MRI can reveal coronary origins, anatomy and coronary artery abnormalities, and infarction in patients with Kawasaki disease.[11]
    • Cardiac MRI has been used to determine myocardial viability and prognosis in a case of in utero myocardial infarction.[12]
  • Myocardial perfusion imaging: This may be useful in evaluating myocardial ischemia and infarction in various disease states.
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Other Tests

  • Classic electrocardiography (ECG) findings for diagnosing ischemia/infarction in adults have been described as follows:
    • Deep Q waves in a completed transmural infarct over the involved areas
    • Peaked T waves hyperacutely
    • ST elevation in the acute phase
    • ST depression when ischemia is present or in the latter stages of acute injury
    • Various dysrhythmias and ectopy secondary to ischemia and irritable myocardium or conductive tissue (see image below)Electrocardiogram in an infant with anomalous origElectrocardiogram in an infant with anomalous origin of the left coronary artery from the pulmonary artery, demonstrating pathologic q waves in leads I and aVL and diffuse ST-T wave changes consistent with an anterolateral infarction.
  • An anterolateral infarct is demonstrated with abnormal deep (>3 mm) and wide (>30 ms) q waves in leads I, aVL, V5, and V6, with absent q waves in leads II, III, and aVF.
  • The QRS axis is typically normal, although in some patients, a left superior axis is observed.
  • ST-segment changes diagnostic of transmural infarction in adults may be seen in pediatric patients in the absence of coronary occlusion.[13] Additional criteria for diagnosing pediatric ischemia have been described:[14]
    • Wide Q waves (>35ms) with or without Q-wave notching
    • ST-segment elevation (>2mm)
    • Prolonged QTc (>440ms) with accompanying Q-wave abnormalities
  • Exercise myocardial perfusion stress testing has been shown to be safe and useful in assessing myocardial perfusion and for risk stratification in children with Kawasaki disease.[15]
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Procedures

  • Angiographic evaluation of the coronary artery system should be urgently performed but with caution because of the inherent instability of the diseased myocardium.
    • Definitive diagnosis of an anomalous left coronary artery from the pulmonary artery is made.
    • Aortography demonstrates an enlarged right coronary artery (RCA) system with collateralization to the left coronary artery and reflux of contrast into the pulmonary arterial system (ALCAPA).
    • Coronary aneurysm, ectasia, or both is frequently identified in patients with Kawasaki disease.
  • Hemodynamic (oximetric) measurements may demonstrate the following:
    • Decreased systemic venous oxygen content is consistent with low cardiac output.
    • A small left-to-right shunt may be demonstrated by oximetry in the main pulmonary artery if ALCAPA is the diagnosis.
    • Elevated left atrial pressures are secondary to reduced left ventricular compliance, significant mitral valve insufficiency, or both.
  • Successful percutaneous transluminal coronary angioplasty for proximal coronary stenoses following the arterial switch procedure has been reported in a small number of patients with apparent excellent results 3-5 years later.
  • Postcatheterization effects that require precautions include hemorrhage, vascular disruption after balloon dilation, pain, nausea and vomiting, and arterial or venous obstruction from thrombosis or spasm.
  • Possible complications include rupture of blood vessel, tachyarrhythmias, bradyarrhythmias, and vascular occlusion.
  • The use of cardiac catheterization and percutaneous coronary interventions appears to be less in adolescents with acute myocardial infarction (29%) than in adults (40-50%) with acute myocardial infarction in review of the NIS. This may be due to a higher incidence of coronary vasospasm and subendocardial acute myocardial infarction in adolescents.[3]
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Contributor Information and Disclosures
Author

Louis I Bezold, MD  Associate Professor and Vice Chair of Inpatient Services, Department of Pediatrics, University of Kentucky College of Medicine; Chief, Division of Pediatric Cardiology, Medical Director, Kentucky Children's Hospital

Louis I Bezold, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Society of Echocardiography, and Society of Pediatric Echocardiography

Disclosure: Nothing to disclose.

Coauthor(s)

Kurt Pflieger, MD, FAAP  Active Staff, Department of Pediatrics, Lake Pointe Medical Center

Kurt Pflieger, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Jeffrey Allen Towbin, MD, MSc, FAAP, FACC, FAHA  Professor, Departments of Pediatrics (Cardiology), Cardiovascular Sciences, and Molecular and Human Genetics, Baylor College of Medicine; Chief of Pediatric Cardiology, Foundation Chair in Pediatric Cardiac Research, Texas Children's Hospital

Jeffrey Allen Towbin, MD, MSc, FAAP, FACC, FAHA is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American College of Cardiology, American College of Sports Medicine, American Heart Association, American Medical Association, American Society of Human Genetics, Cardiac Electrophysiology Society, New York Academy of Sciences, Society for Pediatric Research, Texas Medical Association, and Texas Pediatric Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Julian M Stewart, MD, PhD  Associate Chairman of Pediatrics, Director, Center for Hypotension, Westchester Medical Center; Professor of Pediatrics and Physiology, New York Medical College

Julian M Stewart, MD, PhD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Gilbert Z Herzberg, MD  Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Consulting Staff, Department of Pediatrics, Sound Shore Medical Center

Gilbert Z Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD  Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

References

  1. Concheiro-Guisan A, Sousa-Rouco C, Fernandez-Santamarina I, Gonzalez-Carrero J. Intrauterine myocardial infarction: unsuspected diagnosis in the delivery room. Fetal Pediatr Pathol. Jul-Aug 2006;25(4):179-84. [Medline].

  2. CDC. National Vital Statistics Report: Acute myocardial infarction. 1998 Nov; 47(9). Available at: http://www.disastercenter.com/cdc/aacutcar.html. Accessed September 30, 2008. [Full Text].

  3. Mahle WT, Campbell RM, Favaloro-Sabatier J. Myocardial infarction in adolescents. J Pediatr. Aug 2007;151(2):150-4. [Medline].

  4. Oglesby P. The international cooperative study on epidemiology. Circulation. Jun 1970;41(6):895-7. [Medline].

  5. Lane JR, Ben-Shachar G. Myocardial infarction in healthy adolescents. Pediatrics. Oct 2007;120(4):e938-43. [Medline].

  6. Safi M, Taherkhani M, Badalabadi RM, Eslami V, Movahed MR. Coronary aneurysm and silent myocardial infarction in an adolescent secondary to undiagnosed childhood Kawasaki disease. Exp Clin Cardiol. Spring 2010;15(1):e18-9. [Medline]. [Full Text].

  7. Hunley TE, Kon V, Jabs K. Myocardial infarction in chronic kidney disease. Pediatrics. Jul 2008;122(1):223-4; author reply 224. [Medline].

  8. Ardoin SP, Sandborg C, Schanberg LE. Management of dyslipidemia in children and adolescents with systemic lupus erythematosus. Lupus. 2007;16(8):618-26. [Medline].

  9. Koestenberger M, Nagel B, Gamillscheg A, Temmel W, Cvirn G, Beitzke A. Myocardial infarction in an adolescent: anomalous origin of the left main coronary artery from the right coronary sinus in association with combined prothrombotic defects. Pediatrics. Aug 2007;120(2):e424-7. [Medline].

  10. Fyfe DA, Ketchum D, Lewis R, et al. Tissue Doppler imaging detects severely abnormal myocardial velocities that identify children with pre-terminal cardiac graft failure after heart transplantation. J Heart Lung Transplant. May 2006;25(5):510-7. [Medline].

  11. Tacke CE, Kuipers IM, Groenink M, Spijkerboer AM, Kuijpers TW. Cardiac magnetic resonance imaging for noninvasive assessment of cardiovascular disease during the follow-up of patients with kawasaki disease. Circ Cardiovasc Imaging. Nov 1 2011;4(6):712-20. [Medline].

  12. Whitham JK, Hasan BS, Schamberger MS, Johnson TR. Use of cardiac magnetic resonance imaging to determine myocardial viability in an infant with in utero septal myocardial infarction and ventricular noncompaction. Pediatr Cardiol. Sep 2008;29(5):950-3. [Medline].

  13. Gazit AZ, Avari JN, Balzer DT, Rhee EK. Electrocardiographic diagnosis of myocardial ischemia in children: is a diagnostic electrocardiogram always diagnostic?. Pediatrics. Aug 2007;120(2):440-4. [Medline].

  14. Towbin JA, Bricker JT, Garson A Jr. Electrocardiographic criteria for diagnosis of acute myocardial infarction in childhood. Am J Cardiol. Jun 15 1992;69(19):1545-8. [Medline].

  15. Lim CW, Ho KT, Quek SC. Exercise myocardial perfusion stress testing in children with Kawasaki disease. J Paediatr Child Health. Jul-Aug 2006;42(7-8):419-22. [Medline].

  16. Sugahara Y, Ishii M, Muta H, Iemura M, Matsuishi T, Kato H. Warfarin therapy for giant aneurysm prevents myocardial infarction in Kawasaki disease. Pediatr Cardiol. Mar 2008;29(2):398-401. [Medline].

  17. Ahn YK, Jeong MH, Bom HS, et al. Myocardial infarction with Moyamoya disease and pituitary gigantism in a young female patient. Jpn Circ J. Aug 1999;63(8):644-8. [Medline].

  18. Bagby GC Jr, Goldman RD, Newman HC, Means JF. Acute myocardial infarction due to childhood lymphoma. N Engl J Med. Aug 17 1972;287(7):338-40. [Medline].

  19. Berenson GS, Srinivasan SR, Hunter SM, et al. Risk factors in early life as predictors of adult heart disease: the Bogalusa Heart Study. Am J Med Sci. Sep 1989;298(3):141-51. [Medline].

  20. Berry CL. Myocardial ischaemia in infancy and childhood. J Clin Pathol. Jan 1967;20(1):38-41. [Medline].

  21. Bex JP, Laborde F, Baillot F, Martelli H, Hazan E. [Myocardial infarction in an infant without coronary artery birth anomalies]. Arch Mal Coeur Vaiss. May 1980;73(5):535-7. [Medline].

  22. Burns JC, Shike H, Gordon JB, et al. Sequelae of Kawasaki disease in adolescents and young adults. J Am Coll Cardiol. Jul 1996;28(1):253-7. [Medline].

  23. Celermajer DS, Sholler GF, Howman-Giles R, Celermajer JM. Myocardial infarction in childhood: clinical analysis of 17 cases and medium term follow up of survivors. Br Heart J. Jun 1991;65(6):332-6. [Medline].

  24. Coggon D, Margetts B, Barker DJ, et al. Childhood risk factors for ischaemic heart disease and stroke. Paediatr Perinat Epidemiol. Oct 1990;4(4):464-9. [Medline].

  25. Dhillon R, Clarkson P, Donald AE, et al. Endothelial dysfunction late after Kawasaki disease. Circulation. Nov 1 1996;94(9):2103-6. [Medline].

  26. Esterly JR, Oppenheimer EH. Some aspects of cardiac pathology in infancy and childhood. IV. Myocardial and coronary lesions in cardiac malformations. Pediatrics. Jun 1967;39(6):896-903. [Medline].

  27. Fukuda T, Ishibashi M, Shinohara T, et al. Follow-up assessment of the collateral circulation in patients with Kawasaki disease who underwent dipyridamole stress technetium-99m tetrofosmin scintigraphy. Pediatr Cardiol. Sep-Oct 2005;26(5):558-64. [Medline].

  28. Garcia RE, Moodie DS. Routine cholesterol surveillance in childhood. Pediatrics. Nov 1989;84(5):751-5. [Medline].

  29. Gattorno M, Falcini F, Ravelli A, et al. Outcome of primary antiphospholipid syndrome in childhood. Lupus. 2003;12(6):449-53. [Medline].

  30. Gunal N, Kara N, Cakar N, et al. Cardiac involvement in childhood polyarteritis nodosa. Int J Cardiol. Aug 8 1997;60(3):257-62. [Medline].

  31. Haitas B, Baker SG, Meyer TE, et al. Natural history and cardiac manifestations of homozygous familial hypercholesterolaemia. Q J Med. Jul 1990;76(279):731-40. [Medline].

  32. Hancock SL, Donaldson SS, Hoppe RT. Cardiac disease following treatment of Hodgkin's disease in children and adolescents. J Clin Oncol. Jul 1993;11(7):1208-15. [Medline].

  33. Hawkins MM, Kingston JE, Kinnier Wilson LM. Late deaths after treatment for childhood cancer. Arch Dis Child. Dec 1990;65(12):1356-63. [Medline].

  34. Isaka N, Nakano T. [Myocardial infarction in childhood]. Ryoikibetsu Shokogun Shirizu. 1996;(12):679-83. [Medline].

  35. Israels SJ, Michelson AD. Antiplatelet therapy in children. Thromb Res. 2006;118(1):75-83. [Medline].

  36. Kampmann C, Kuroczynski W, Trubel H, et al. Late results after PTCA for coronary stenosis after the arterial switch procedure for transposition of the great arteries. Ann Thorac Surg. Nov 2005;80(5):1641-6. [Medline].

  37. Kondo C. Myocardial perfusion imaging in pediatric cardiology. Ann Nucl Med. Oct 2004;18(7):551-61. [Medline].

  38. Kovacs CS, Sanfilippo AJ, Burggraf GW. Anterior wall myocardial infarction in a 15-year-old diabetic female associated with spontaneously resolving coronary thrombosis. Can J Cardiol. Sep 1992;8(7):733-6. [Medline].

  39. Kreutzer U, Krulls-Munch J, Angres M, Schiessler A. [Successful resuscitation of a patient with ventricular fibrillation in Bland-White-Garland syndrome in adulthood. A case report]. Z Kardiol. Jul 1998;87(7):560-5. [Medline].

  40. L'Ecuyer TJ, Poulik JM, Vincent JA. Myocardial infarction due to coronary abnormalities in pulmonary atresia with intact ventricular septum. Pediatr Cardiol. Jan-Feb 2001;22(1):68-70. [Medline].

  41. Lindblade CL, Kirkpatrick EC, Ebenroth ES. Eosinophilic myocarditis presenting with pediatric myocardial infarction. Pediatr Cardiol. Jan-Feb 2006;27(1):162-5. [Medline].

  42. Long WA, Willis PW 4th, Henry GW. Childhood traumatic infarction causing left ventricular aneurysm: diagnosis by two-dimensional echocardiography. J Am Coll Cardiol. Jun 1985;5(6):1478-83. [Medline].

  43. Mavrogeni S, Papadopoulos G, Douskou M, et al. Magnetic resonance angiography, function and viability evaluation in patients with Kawasaki disease. J Cardiovasc Magn Reson. 2006;8(3):493-8. [Medline].

  44. McMahon CJ, Nihill MR, Denfield S. Neoaortic root dilation associated with left coronary artery stenosis following arterial switch procedure. Pediatr Cardiol. Jan-Feb 2003;24(1):43-6. [Medline].

  45. Monagle P. Thrombosis in pediatric cardiac patients. Semin Thromb Hemost. Dec 2003;29(6):547-55. [Medline].

  46. Najean Y, Haguenauer O. Long-term (5 to 20 years) Evolution of nongrafted aplastic anemias. The Cooperative Group for the Study of Aplastic and Refractory Anemias. Blood. Dec 1 1990;76(11):2222-8. [Medline].

  47. Neufeld EJ. Inherited dyslipidemias in childhood. Curr Opin Pediatr. Dec 1993;5(6):707-11. [Medline].

  48. Neufeld HN, Blieden LC. Coronary artery disease in children. Postgrad Med J. Mar 1978;54(629):163-70. [Medline].

  49. Newburger JW, Burns JC. Kawasaki disease. Vasc Med. 1999;4(3):187-202. [Medline].

  50. Newburger JW, Takahashi M, Gerber MA, et al. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Pediatrics. Dec 2004;114(6):1708-33. [Medline]. [Full Text].

  51. Ou P, Mousseaux E, Azarine A, et al. Detection of coronary complications after the arterial switch operation for transposition of the great arteries: first experience with multislice computed tomography in children. J Thorac Cardiovasc Surg. Mar 2006;131(3):639-43. [Medline].

  52. Pahl E, Naftel DC, Kuhn MA, et al. The impact and outcome of transplant coronary artery disease in a pediatric population: a 9-year multi-institutional study. J Heart Lung Transplant. Jun 2005;24(6):645-51. [Medline].

  53. Pfafferott C, Wirtzfeld A, Permanetter B. Atypical Kawasaki syndrome: how many symptoms have to be present?. Heart. Dec 1997;78(6):619-21. [Medline]. [Full Text].

  54. Radford DJ, Sondheimer HM, Williams GJ, Fowler RS. Mucocutaneous lymph node syndrome with coronary artery aneurysm. Am J Dis Child. Jun 1976;130(6):596-8. [Medline].

  55. Schaison G, Jacquillat C, Lemercier N, Weil M, et al. [Acute leukemia in childhood: present status of 100 cases after 7 years of complete remission (author's transl)]. Bull Cancer. 1980;67(3):261-8. [Medline].

  56. Senzaki H, Chen CH, Ishido H, et al. Arterial hemodynamics in patients after Kawasaki disease. Circulation. Apr 26 2005;111(16):2119-25. [Medline]. [Full Text].

  57. Shaukat N, Ashraf S, Mebewu A, et al. Myocardial infarction in a young adult due to Kawasaki disease. A case report and review of the late cardiological sequelae of Kawasaki disease. Int J Cardiol. Jun 1993;39(3):222-6. [Medline].

  58. Simoes MV, Felix PR, Marin-Neto JA. Acute myocardial infarction complicating the clinical course of dilated cardiomyopathy in childhood. Chest. Jan 1992;101(1):271-2. [Medline].

  59. Smith BA, Grider DJ. Sudden death in a young adult: sequelae of childhood Kawasaki disease. Am J Emerg Med. Jul 1993;11(4):381-3. [Medline].

  60. Srinivasan SR, Berenson GS. Serum apolipoproteins A-I and B as markers of coronary artery disease risk in early life: the Bogalusa Heart Study. Clin Chem. Jan 1995;41(1):159-64. [Medline].

  61. Su JT, Chung T, Muthupillai R, et al. Usefulness of real-time navigator magnetic resonance imaging for evaluating coronary artery origins in pediatric patients. Am J Cardiol. Mar 1 2005;95(5):679-82. [Medline].

  62. Takeuchi S, Imamura H, Katsumoto K, et al. New surgical method for repair of anomalous left coronary artery from pulmonary artery. J Thorac Cardiovasc Surg. Jul 1979;78(1):7-11. [Medline].

  63. van Pelt NC, Wilson NJ, Lear G. Severe coronary artery disease in the absence of supravalvular stenosis in a patient with Williams syndrome. Pediatr Cardiol. Sep-Oct 2005;26(5):665-7. [Medline].

  64. Vrsanska V, Bircak J. [Risk factors for cardiovascular diseases in childhood]. Bratisl Lek Listy. Sep 1989;90(9):670-5. [Medline].

 
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Electrocardiogram in an infant with anomalous origin of the left coronary artery from the pulmonary artery, demonstrating pathologic q waves in leads I and aVL and diffuse ST-T wave changes consistent with an anterolateral infarction.
 
 
 
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