Acute anterior ST elevation myocardial infarction caused by paradoxical embolus in young patient having PFO

Yousif Abusalma, Ram Ghasil, Rehaan Nensey, Hanif Mustafa, Russell Davis, Abdel Yousif, Vinoda Sharma

Introduction and background: Coronary thromboembolic phenomenon can be the main pathophysiology in up to 3%-7% of acute coronary syndromes presentation. However, many times it is missed in the differential diagnosis of acute coronary syndromes. Paradoxical coronary artery embolism is a rare cause of acute myocardial infarction, and it should be thought of in patients presenting with myocardial infarction with low risk profile for atherosclerotic coronary artery disease.

Case summary: A 25-year-old woman presented with severe cardiac sounding chest pain. Her ECG confirmed ST elevation in the anterior precordial leads, elevated cardiac enzymes and apical, apicolateral hypokinesia with preserved Left Ventricular Systolic Function (LVSF) on transthoracic echocardiogram. Coronary angiogram revealed at the time distal Left Anterior Descending (LAD) artery blockage with TIMI I flow. Subsequent cardiac Computed Tomography Coronary angiogram (CTCA) 48 hours later on revealed normal good flow in the distal LAD.

Conclusion and learning points:

• This case puts the emphasis on the rare causes of acute myocardial infarction in a patient with a PFO which led to paradoxical coronary artery embolization.

• Coronary artery embolism is well recognised aetiology of Acute Coronary Syndrome (ACS), but paradoxical coronary artery embolism is seldomly observed. Hence, a high index of clinical suspicion is required for this diagnosis.

• Indeed, reaching the right diagnosis in such condition is crucial. The right diagnosis would influence management and prognosis, as it would entail closure of the defect to prevent further catastrophic events.