Abstract 16294: A Case of Paradoxical Coronary Embolism in a Patient With Undiagnosed Malignancy

Abstract

Introduction: Coronary embolism is a rare cause of acute myocardial infarction (AMI) in comparison with atherosclerotic plaque rupture. We present a case of an inferior ST elevation myocardial infarction caused by coronary embolism. The source was thought to be from the combination of deep vein thrombosis (DVT) and patent foramen ovale (PFO), accounting for a unique presentation and pathophysiology. Case: An 86-year-old female with a history of hypertension, non-small cell lung cancer status post resection with no residual disease, presented with a three-day history of epigastric discomfort, dyspnea on exertion and confusion. On presentation, she was afebrile with normal vital signs. Physical exam revealed epigastric pain on palpation. Initial labs were significant for high sensitivity troponin elevation to 9591 ng/L. ECG showed ST elevations in leads II, III, aVF. Coronary angiogram showed distal left anterior descending artery 71% stenosis and left posterior descending artery 99% stenosis. Given multiple distal locations concerning for coronary emboli, coronary angioplasty was done without stenting given no evidence of plaque rupture. After the angiogram, patient was found to have slurred speech and left sided facial droop. CT head showed multiple embolic infarcts. A transesophageal echocardiogram revealed a small PFO but no valvular vegetation/calcification or left atrial appendage thrombus. Lower extremity dopplers demonstrated lower extremity DVT. CT abdomen showed a pancreatic mass with hepatic metastasis, concerning for metastatic pancreatic adenocarcinoma. Patient was started on atorvastatin and aspirin only as AMI was due to a suspected embolic event. She received an IVC filter due to contraindication of anticoagulation in acute stroke and discharged to follow up with Oncology outpatient. Conclusions: In comparison to atherosclerotic plaque rupture, AMI as a result of an embolic coronary phenomena is rare. In fact, less than 1% of AMIs are caused by paradoxical embolism due to a PFO. There are many case reports about embolic AMI due to valvular vegetation or calcification. However, paradoxical coronary embolism due to PFO should be considered in patients with risk factors for a hypercoagulable state such as malignancy or DVT.