Abstract 13484: Acute Coronary Syndrome: A Unique Presentation of Libman Sacks Endocarditis

Abstract

Introduction: Systemic Lupus Erythematosus (SLE) is a chronic inflammatory disease with multiorgan involvement. Cardiac involvement can range from endocarditis to cardiomyopathy. We present a case of SLE complicated by Libman Sacks Endocarditis (LSE) presenting as an acute coronary syndrome (ACS). Case Presentation: A 34 year old male with a history of SLE, DVT/PE, RCA thrombus status post thrombectomy, noncompliance and drug abuse presented to the hospital with complaints of central chest pain associated with right neck, jaw, mouth and arm pain. Vitals were stable. Troponin increased from 0.8 to 13. EKG demonstrated inferior Q waves and ST elevation. CT angiogram was negative for pulmonary embolism but revealed a mobile aortic mass involving the right coronary cusp at the origin of right coronary artery. Transthoracic echocardiogram confirmed this finding. He was started on an infusion of heparin. Surgical evaluation was obtained for emergent thrombectomy and coronary artery bypass grafting. Due to the aortic root thrombus, coronary angiogram was not performed. Lower extremity venous and arterial doppler revealed chronic bilateral DVTs as well as a thrombus in the right common femoral artery. A right heart catheterization demonstrated normal cardiac output and intracardiac filling pressures.Rheumatology was consulted and the patient’s presentation was deemed secondary to Libman sacks endocarditis in the setting of untreated SLE. The pro-coagulant state was chronic and exacerbated secondary to medical noncompliance. Patient was started on hydroxychloroquine with plans for long term anti-coagulation with warfarin in addition to daily aspirin. His symptoms subsided and was discharged home with plans for outpatient follow up. Discussion: Libman sacks endocarditis is a form of noninfectious endocarditis in SLE patients with deposition of thrombi on heart valves. In literature it has been reported to cause valvular dysfunction and cerebrovascular thromboembolism. Our case was unique as it represents a rare manifestation of LSE with an embolic event to a coronary vessel causing ACS. The patient was known to have had prior LSE and due to the complexity of his case and history of medical noncompliance, he was deemed a poor surgical candidate.