© 2015, Wiley Periodicals, Inc. DOI: 10.1111/joic.12171
CLINICAL IMAGE Acute Myocardial Infarction Due to Coronary Artery Embolus J. SAWALLA GUSEH, M.D., and DAVID M. DUDZINSKI, M.D. From the Corrigan Minehan Heart Center , Yawkey Center for Outpatient Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
(J Interven Cardiol 2015;28:313–314)
Figure 1. (A) EKG revealed AF and inferoposteroapical ST elevations; (B) Left coronary arteriography showed a lack of atherosclerosis; (C) Right coronary arteriography revealed an embolus. Disclosure Statement: JSG has no financial relationships with a commercial entity producing healthcare-related products and/or services. Address for reprints: J. Sawalla Guseh, M.D., Fellow in Cardiovascular Medicine, 55 Fruit Street, Corrigan Minehan Heart Center, Yawkey Center for Outpatient Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114. Fax: 1-617-724-6767; e-mail: [email protected]
Vol. 28, No. 3, 2015
Journal of Interventional Cardiology
313
GUSEH AND DUDZINSKI
A 92-year-old woman presented with sudden crushing chest pain awakening her from sleep. She reported 3 weeks of antecedent fatigue. Electrocardiogram revealed atrial fibrillation and inferoposteroapical ST-segment elevations (Fig. 1, Panel A) both new versus prior tracing. Coronary angiography showed no evidence of atherosclerosis (Panel B) but revealed a focal filling defect in the distal right coronary artery (Panel C), which in the absence of atherosclerosis with acute presentation suggests embolism. New atrial fibrillation was believed to underlie antecedent fatigue. Percutaneous embolectomy was deemed high risk of causing distal embolization and deferred. Agitated saline echocardiography excluded patent foramen
314
ovale and left ventricle dysfunction; biatrial dilatation was present and the proximal aspect of the left atrial appendage and 3 of the 4 left-sided pulmonary veins were visualized, but no discrete intracardiac thrombus was present. Her CHADS2 atrial fibrillation stroke score was 2 (age and hypertension) but CHA2DS2VASc score was 6 (age, gender, hypertension), given its inclusion of systemic embolism. Anticoagulation was initiated. Coronary artery embolism is a rare nonatherosclerotic etiology that should be considered in the differential diagnosis of acute myocardial infarction. No management consensus exists, but aspiration, intracoronary thrombolysis, and stenting are possible reperfusion strategies.
Journal of Interventional Cardiology
Vol. 28, No. 3, 2015
CLINICAL IMAGE Acute Myocardial Infarction Due to Coronary Artery Embolus J. SAWALLA GUSEH, M.D., and DAVID M. DUDZINSKI, M.D. From the Corrigan Minehan Heart Center , Yawkey Center for Outpatient Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
(J Interven Cardiol 2015;28:313–314)
Figure 1. (A) EKG revealed AF and inferoposteroapical ST elevations; (B) Left coronary arteriography showed a lack of atherosclerosis; (C) Right coronary arteriography revealed an embolus. Disclosure Statement: JSG has no financial relationships with a commercial entity producing healthcare-related products and/or services. Address for reprints: J. Sawalla Guseh, M.D., Fellow in Cardiovascular Medicine, 55 Fruit Street, Corrigan Minehan Heart Center, Yawkey Center for Outpatient Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114. Fax: 1-617-724-6767; e-mail: [email protected]
Vol. 28, No. 3, 2015
Journal of Interventional Cardiology
313
GUSEH AND DUDZINSKI
A 92-year-old woman presented with sudden crushing chest pain awakening her from sleep. She reported 3 weeks of antecedent fatigue. Electrocardiogram revealed atrial fibrillation and inferoposteroapical ST-segment elevations (Fig. 1, Panel A) both new versus prior tracing. Coronary angiography showed no evidence of atherosclerosis (Panel B) but revealed a focal filling defect in the distal right coronary artery (Panel C), which in the absence of atherosclerosis with acute presentation suggests embolism. New atrial fibrillation was believed to underlie antecedent fatigue. Percutaneous embolectomy was deemed high risk of causing distal embolization and deferred. Agitated saline echocardiography excluded patent foramen
314
ovale and left ventricle dysfunction; biatrial dilatation was present and the proximal aspect of the left atrial appendage and 3 of the 4 left-sided pulmonary veins were visualized, but no discrete intracardiac thrombus was present. Her CHADS2 atrial fibrillation stroke score was 2 (age and hypertension) but CHA2DS2VASc score was 6 (age, gender, hypertension), given its inclusion of systemic embolism. Anticoagulation was initiated. Coronary artery embolism is a rare nonatherosclerotic etiology that should be considered in the differential diagnosis of acute myocardial infarction. No management consensus exists, but aspiration, intracoronary thrombolysis, and stenting are possible reperfusion strategies.
Journal of Interventional Cardiology
Vol. 28, No. 3, 2015
