Abstract 18687: Cardio-Rheumatology: Coronary and Cerebrovascular Thromboses in Antiphospholipid Antibody Syndrome

Abstract

Description of Case: A 27-year-old male with antiphospholipid antibody syndrome (APLS) with a high-risk antibody profile presented for cardiac evaluation. APLS was diagnosed after presentation with acute cardioembolic stroke requiring thrombolysis. Echocardiography showed a normal ejection fraction, with multiple small echo-densities attached to the anterior and posterior leaflet tips of the mitral valve suggesting non-bacterial thrombotic endocarditis (NBTE). The patient was treated with warfarin and aspirin was recommended but declined. As the patient reported lightheadedness, a cardiac rhythm monitor was placed and showed two episodes of non-sustained ventricular tachycardia (NSVT). A cardiac MRI was then obtained, showing multifocal, subendocardial and mesocardial delayed gadolinium enhancement suggesting fibrosis, in a distribution most consistent with a multivessel embolic event. A CT coronary angiogram was performed to further evaluate the coronary arteries, revealing normal coronary anatomy, free from atherosclerotic plaque or thrombus. Beta-blocker therapy was initiated for arrhythmic episodes, with resolution of symptoms and no recurrence of NSVT on follow-up monitoring. Left ventricular (LV) function continued to remain preserved on follow-up imaging, with no progression of mitral valve vegetations on anticoagulation. Discussion: Cardiac involvement in APLS has been well described but largely centers around valvular disease and de novo venous and arterial thromboses. This case of cerebrovascular and coronary pathology in APLS as a likely consequence of thromboembolic phenomena is an unusual presentation and highlights the potential downstream consequences of left-sided valvular NBTE. A high index of suspicion is required to specifically evaluate for myocardial scarring despite normal LV function on echocardiography. The presence of myocardial fibrosis in these cases can act as a focus for scar-related ventricular arrhythmias, which if diagnosed and treated in a timely manner can limit further cardiovascular complications for the patient.