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Atrial Infarction Cardiovascular and Metabolic Science Review Vol. 31 No. 1 January-March 2020 Atrial infarction: a literature review Infarto atrial: revisión de la literatura Laura Duque-González,* María José Orrego-Garay,‡ Laura Lopera-Mejía,§ Mauricio Duque-Ramírez|| Keywords: Infarction, atrium, ABSTRACT RESUMEN atrial fibrillation, embolism and Atrial infarction is an often-missed entity that has been El infarto atrial es una entidad frecuentemente olvidada, thrombosis. described in association with ventricular infarction ha sido descrita en asociación con el infarto ventricular or as an isolated disease, which is mainly caused by o de manera aislada y es causado principalmente Palabras clave: atherosclerosis. The electrocardiographic diagnostic por aterosclerosis. Los criterios diagnósticos Infarto, aurícula, criteria were proposed more than fifty years ago and electrocardiográficos fueron propuestos hace más de 50 fibrilación auricular, have not yet been validated. The diagnosis is based on años y aún no han sido validados. El diagnóstico se basa en embolia y trombosis. elevations and depressions of the PTa segment and changes el hallazgo de elevación o depresión del segmento PTa y de in the P wave morphology. However, supraventricular alteraciones en la morfología de la onda P; sin embargo, arrhythmias such as atrial fibrillation are the most common las arritmias supraventriculares como la fibrilación atrial finding and often predominate in the clinical presentation. son las más comunes y con frecuencia predominan en el Early recognition and treatment may prevent serious cuadro clínico. Un rápido reconocimiento y tratamiento complications such as mural thrombosis or atrial rupture. pueden ayudar a prevenir complicaciones graves como la Further studies need to be carried out in order to establish trombosis mural o la ruptura auricular. Se necesitan más unified criteria for the diagnosis and the actual prevalence estudios para establecer criterios diagnósticos unificados of this entity. y para conocer la prevalencia real de esta entidad. INTRODUCTION The presence of supraventricular arrhythmias, such as atrial fibrillation, entricular infarction (VI) is a well known wandering pacemaker, atrial tachycardia, and Vpathology that in most of the cases of atrial premature complexes, might suggest atrial infarction (AI), covers all the attention the existence of AI in the context of an of the clinical presentation. A wide variety of acute coronary syndrome, as only 20% of presentations can make the diagnosis of this cases of isolated VI present supraventricular * Internist, Cardiology pathology more difficult. Most of the times arrhythmias, differently occurs in AI, in which fellow, CES University. it is associated with ventricular ischemia, but the incidence increases up to 70%.6 ‡ General Physician, in cases of hypertrophy, myocarditis, COPD Not only arrhythmias are present in these CES Cardiología. § Medical Student, (chronic obstructive pulmonary disease), patients, more threatening complications such as CES University. pulmonary hypertension or muscular dystrophy, thrombosis, atrial wall rupture and heart failure || Cardiologist, AI can be an isolated disease.1,2 The two atria decompensation, can lead to a high mortality.2,7 Electrophysiologist, can be compromised,www.medigraphic.org.mx or only one of them, The purpose of this review is to bring CES Cardiología. being the right atrium the most frequent one.3 attention to a frequently unnoticed disease. Antioquia, Colombia. Almost a century ago, Clerc et al. described the first case report documented in literature,4 Risk factors and pathophysiology Received: and in 1942 a case series was described by 28/01/2020 5 Accepted: Cushing et al. Until today, there are no unified An exact incidence of AI in admitted patients 08/04/2020 criteria for the diagnosis of AI. with VI is unknown, autopsy studies had been Cardiovasc Metab Sci 2020; 31 (1): 17-24 www.medigraphic.com/cms 18 Duque-González L et al. Atrial infarction broadly variable with incidences that range Nevertheless, mostly of AI occur from 0.7% to 42%,2 a bigger study conducted concurrently with VI,1,2,5,8,11 in this context, left by Cushing et al, demonstrated that 31 of 182 ventricle infarcts are more prevalent, probably cases of VI resulted in atrial ischemia, with explaining why in some series the left atrium is an incidence of 17%, proven with autopsy mostly compromised.11 examination.5 The AI occurs when blood supplying arteries The main cause of AI, as in VI is are occluded (Figure 1), and some of its clinical atherosclerosis,2,8-11 it has also been associated and electrocardiographic (ECG) manifestations, with other entities like COPD with cor like supraventricular tachycardias,1,3,8,11,12 are pulmonale, elevated chamber pressure explained by the compromise of structures such plus hypoxia, that is consequence of the as the sinoatrial (SA) node and atrioventricular pulmonary disease itself,2,8,9 primary pulmonary (AV) node, which are irrigated by branches of hypertension,2,8-10 muscular dystrophy and the main arteries that nourish the atria. Friedreich’s ataxia.2,9 The ramus ostii cava superioris (ROCS) Due to the thin atrial wall (2-3 mm), originates in 60% of people from the proximal most AI are transmural,2,8 they occur mainly right coronary artery (RCA), and in 40% from the in the right atrium and are more frequently proximal left circumflex artery (LCx); irrigating found on the atrial appendages;1-3,5,8-10 the SA node through its course along the atrium, when the right coronary artery is occluded passing across the interatrial groove forming the it does commonly in the first 2-3 cm, interatrial branches, towards its ending near therefore compromising the atrial branches; the superior vena cava opening. The right and interestingly in the study conducted by left intermediate and posterior atrial arteries, Cushing et al. occlusion of left coronary artery branches from the RCA and LCx respectively, and its atrial branches occurred in 65% of anastomosing with the ROCS in the interatrial cases, but the incidence of AI was still higher groove or over the atrium body. The AV node in the right atrium. This could be explained artery arises commonly from the RCA (87%), in by the higher oxygen concentration in the left 7% of cases from the LCx and in 10% from both. atrium, suggesting that there may be other Due to the variability in atrial blood supply, the mechanisms involved.5,8 clinical and ECG findings are inconsistent.8,13 LAD Aorta RCA LCx ROCS SVC PA ROCS (right) PA ROCS (left) LAA Aorta Right Left intermediate LAD intermediate Right RA atrial artery atrial artery intermediate RCA SVC atrial artery www.medigraphic.org.mx IVC Figure 1: Atrium blood supply (SVC = superior vena cava, IVC = inferior vena cava, PA = pulmonary artery, RA = right atrium, LAA = left atrial appendage, RCA = right coronary artery, LAD = left anterior descending, LCx = left circumflex, ROCS = ramus ostii cava superioris). Cardiovasc Metab Sci 2020; 31 (1): 17-24 www.medigraphic.com/cms Duque-González L et al. Atrial infarction 19 Diagnosis However, these major criteria have not been observed in subsequent studies and have To this day, there are no unified criteria for not yet been validated.20 the diagnosis of AI. The clinical presentation Recently, Yildiz et. al conducted a depends mostly on the area and extension of retrospective study that included patients the affected myocardium.8 In addition, ECG with inferior-wall STEMI, finding PTa segment findings are subtle and nonspecific, making the displacement only in a few patients with AI diagnosis difficult.14 and not in patients without this entity. In the AI associated with VI is the most common P-wave parameters analyzed, the P-wave type, especially with acute inferior and right duration was longer, and the amplitude was VI;15,16 however some cases of isolated AI lower in inferior leads in patients with AI have been described.17 In 1991, Wong et al. than in the control group. They suggest a concluded that if a patient presents angina, P-wave duration of ≥ 95.5 ms in lead II for AI paroxysmal supraventricular arrhythmias, diagnosis.21 changes in the PTa segment and elevation of Changes in the PTa segment usually last cardiac enzymes, without evidence of VI, an between a few hours to a few days. It is believed isolated AI is a probable diagnosis.18 that these changes improve with infarction In 1948, Hellerstein reported the first case treatment. Besides, it is also believed that of a patient that had an ante-mortem diagnosis PTa deviations occur before any other ECG of AI based on the ECG.1 The ante-mortem alterations.6 diagnosis depends on the ECG findings, based Liu et al. suggested that AI must be on elevations and depressions of the PTa suspected when a patient presents atrial segment (representing atrial repolarization) and arrhythmias and an associated VI. In one of the changes in the P wave; under normal conditions cases described by Liu et al, the VI diagnosis atrial repolarization in the ECG takes place at confirmed with an autopsy was not seen in the the same time as the ventricular depolarization ante-mortem ECG, but the AI was in fact seen. (QRS complex), explaining why it is not usually This is why it is advised that in the presence of seen in the ECG, as the QRS complex voltage ECG changes suggestive of AI, an associated VI is higher. Conversely, a diseased atrium has must be assumed and treated.11 its repolarization (PTa segment) earlier in the The sensitivity or specificity of the PTa ECG, therefore the changes can be identified segment deviations for the AI diagnosis are in the PR segment. However, these changes unknown.6 are not always present in the ECG, this might be due to the low voltage generated by the The infarction location, in theory, would atria and because these changes are generally determine the PTa segment deviation: masked by the underlying alterations in the ventricular depolarization.2,11 Also PR segment • When there is an ischemia of the posterior prolongation and P wave axis changes have wall: PTa segment is elevated in lead II and been reported.19 III, with a reciprocal depression in lead I Supraventricular arrhythmias are the most (Figure 3).
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