Coronary Embolic Phenomena: High-Impact, Low-Frequency Events

Abstract

Coronary embolic phenomena (CEP) are difficult to diagnose yet carry potentially devastating clinical consequences. The goal of this chapter is to outline key processes and pathophysiologic mechanisms underlying CEP, primarily in the context of acute coronary syndrome (ACS). Not surprisingly, most reported cases of CEP occur in the left coronary circulation, but some right-sided events have been reported. Overall, causes include thrombotic, septic/infectious, neoplastic, valverelated, and iatrogenic mechanisms such as air embolization. Coronary angiography remains the definitive diagnostic and therapeutic approach, with computed tomography being increasingly utilized. Transthoracic echocardiography (TTE) should be part of a routine work up for patients with suspected CEP. Holter/event monitoring for atrial fibrillation may also be indicated in patients with embolic phenomena. Clinical management includes procedural restoration of coronary blood flow, followed by appropriate anticoagulation or antiplatelet therapy, in conjunction with appropriate treatment of any arrhythmias or other associated cardiac manifestations or conditions. Timely diagnosis, based on a high index of suspicion (especially in high-risk population) may be important in improving morbidity and mortality in affected patients. Since CEPs are often underdiagnosed and may be due to a number of heterogeneous causes, the need arises for increasing provider awareness of these important phenomena, as well as for the implementation of appropriate clinical management guidelines.

Facing Adversity during Graduate Medical Training: The Concept of ‘Coping Intelligence’

“…Although rigorous training (drills) and adherence to checklists can help enhance problem-based coping, there will always be situations that can appear hopeless to the provider/trainee. Preparing trainees to cope more effectively with highly stressful and potentially chaotic situations, such as the management of maternal hemorrhage, will be an important aspect of addressing the need for better overall management of the 'emotional burden' associated with low-frequency, high-impact clinical events [60,61].…”