Embolic Myocardial Infarction Research Articles

Embolic Myocardial Infarction due to Mobile Aortic Thrombus Originating From Localised Takayasu Aortitis

Embolic Myocardial Infarction due to Mobile Aortic Thrombus Originating From Localised Takayasu Aortitis

Trends in electrocardiographic and cardiovascular manifestations of patients hospitalised with COVID-19.

Early in the coronavirus disease 2019 (COVID-19) pandemic, a low incidence of cardiovascular complications was reported in Singapore. Little was known about the trend of cardiovascular complications as the pandemic progressed. In this study, we examined the evolving trends in electrocardiographic and cardiovascular manifestations in patients hospitalised with COVID-19. We examined the first 1781 consecutive hospitalised patients with polymerase chain reaction-confirmed COVID-19. We divided the population based on whether they had abnormal heart rate (HR) or electrocardiography (ECG) or normal HR and ECG, comparing the baseline characteristics and outcomes. Cardiovascular complications were defined as acute myocardial infarction, stroke, pulmonary embolism, myocarditis and mortality. The 253 (14.2%) patients who had abnormal HR/ECG at presentation were more likely to be symptomatic. Sinus tachycardia was commonly observed. Troponin I levels (97.0 ± 482.9 vs. 19.7 ± 68.4 ng/L, P = 0.047) and C-reactive protein levels (20.1 ± 50.7 vs. 13.9 ± 24.1 μmol/L, P = 0.003) were significantly higher among those with abnormal HR/ECGs, with a higher prevalence of myocarditis (2.0% vs. 0.5%, P = 0.019), pulmonary embolism (2.0% vs. 0.3%, P = 0.008) and acute myocardial infarction (1.2% vs. 0.1%, P = 0.023). After adjusting for age and comorbidities, abnormal HR/ECG (adjusted odds ratio 4.41, 95% confidence interval 2.21-8.77; P < 0.001) remained independently associated with adverse cardiovascular complications. Over time, there was a trend towards a higher proportion of hospitalised patients with cardiovascular complications. Cardiovascular complications appear to be increasing in proportion over time among hospitalised patients with COVID-19. A baseline ECG and HR measurement may be helpful for predicting these complications.

Cholecystitis may decrease the risk of sudden death: A 2-sample Mendelian randomization study.

Some observational studies have highlighted a significant association between cholecystitis and factors leading to sudden death; however, the specific relationship between the 2 has not been fully elucidated. The primary objective of this study was to elucidate the causal interplay between cholecystitis and augmented risk of sudden cardiac death. We used large-scale genetic summary data from genome-wide association study, genetic summary statistics were sourced from 3 eminent repositories: the UK Biobank (N = 463,010), the FinnGen consortium (N = 215,027), and the European Bioinformatics Institute (N = 471,251). By employing 2-sample Mendelian randomization (MR) to decipher the causal interplay between cholecystitis and sudden death etiologies, a meta-analytical approach was employed to amalgamate the findings derived from these disparate data sources. The primary MR methodologies used included inverse variance weighting with random effects, inverse variance weighting with fixed effects, maximum likelihood, MR-Egger, and weighted median. Subsequently, we performed heterogeneity testing, polyvalency examination, and sensitivity analysis to bolster the robustness of causal relationship assessments. Meta-analysis and amalgamating variegated data sources revealed a statistically significant inverse correlation between cholecystitis and ventricular arrhythmias (odds ratio, 0.896; 95% confidence interval: 0.826-0.971; P = .008). Similarly, an inverse association was observed between cholecystitis and aortic aneurysm (odds ratio, 0.899; 95% confidence interval: 0.851-0.951, P < .001). This study substantiates the absence of a direct causal link between cholecystitis and cerebrovascular accidents (P = .771), pulmonary embolism (P = .071), and acute myocardial infarction (P = .388). A direct causal correlation existed between cholecystitis and sudden death associated with ventricular arrhythmias and aortic aneurysms. The onset of cholecystitis may mitigate the risk of sudden death due to ventricular arrhythmias and aortic aneurysms.

AN OUT OF HOSPITAL CARDIAC ARREST SURVIVOR WITH PRESUMED EMBOLIC MYOCARDIAL INFARCTION: ROLE OF MULTI–MODALITY IMAGING

Abstract Background Myocardial infarction with non–obstructive coronary arteries (MINOCA) refers to a puzzling clinical entity that is characterized by symptoms suggestive of acute coronary syndrome, demonstrates troponin elevation with inconclusive coronary angiogram. The underlying pathophysiologic mechanisms include atherosclerotic cause or non–atherosclerotic causes, such as coronary dissection or coronary embolus. A standardized approach that includes multimodality imaging is necessary to determine underlying aetiology and direct appropriate treatment. Case Summary A 57–year–old male was admitted to our hospital after experiencing cardiac arrest after physical exercise (swimming) treated immediately with cardiac pulmonary resuscitation and two defibrillator–delivered electrical shocks for shockable rhythm before return of spontaneous circulation. Relevant abnormal bloods included a hs–Troponin I elevation. Invasive coronary angiography demonstrated non–obstructed coronary arteries. Subsequent cardiac magnetic resonance imaging (MRI) demonstrated akinesia and an area of subendocardic late gadolinium enhancement in the inferior–lateral wall. This pattern was in keeping with an ischaemic cause, as a recent embolic myocardial infarction. Further investigations, including contrast bubble echocardiogram, were performed in order to identify a cause and source of the embolic infarction and led to the diagnosis of tunnel–like patent foramen ovale with right to left shunting, then confirmed on trans–oesophageal echocardiogram. The patient was treated as myocardial infarction most likely due to embolic phenomena in the presence of a PFO. Therefore, a transvenous ICD was implanted for secondary prevention and the patient underwent percutaneous closure of the PFO. Discussion and Conclusion MINOCA can occur in 5–15% of all acute coronary syndromes and represents a working diagnosis. It is important to identify the underlying aetiology of their presentation to appropriately manage them. In particular, where cardiac MRI demonstraded LGE areas ichaemic patterns, myocardial infarction due to secondary embolism should be considered and the next step in clinical management is to identify potential sources of emboli performing further assessments. Multi–modality imaging with cardiac MRI and echocardiogram (transthoracic, contrast bubble and trans–oesophageal) is important in correctly identifying any source of emboli and the diagnosis of any intra–cardiac shunt.

Recurrent pulmonary embolism and non-ST elevation acute myocardial infarction: current problems of diagnosis and treatment (clinical case)

A clinical case of a patient with recurrent pulmonary embolism (PE) and non-ST elevation acute myocardial infarction (NSTEMI) is presented. Underestimation of the history data, the clinical course of non-massive pulmonary embolism under the mask of syncope, eventually led to the development of massive pulmonary embolism and clinical death of the patient. The article discusses non-massive PE masks, principles of treatment and secondary prevention of venous thromboembolic complications in a patient with acute NSTEMI.

Concomitant occurrences of pulmonary embolism and acute myocardial infarction in acute coronary syndrome patient undergoing percutaneous coronary intervention: a case report.

Concomitant occurrences of pulmonary embolism and acute myocardial infarction in acute coronary syndrome patient undergoing percutaneous coronary intervention: a case report.

Complex Combination of Pulmonary Embolism, Stroke, and ST-Segment Elevation Myocardial Infarction in Young Patient with Recent COVID-19 Infection and Newly Diagnosed Lung Carcinoma

BACKGROUND: Ischemic stroke, pulmonary embolism (PE), and acute ST-segment elevation myocardial infarction (STEMI) are very rarely all present in younger patients without classical risk factors or a family history of dyslipidemia or cardiovascular disease. They represent a medical emergency and necessitate fast diagnosis, treatment, and search for etiology, not explained purely by atherosclerosis. Thrombophilia testing should be considered in younger patients with several major thrombotic episodes, although there is much disagreement concerning the importance of homocysteine level testing in patients with arterial and venous thrombotic events, including PE. COVID-19 infection may trigger several thrombotic complications caused by unique immunothrombotic processes. CASE PRESENTATION: A 44-year-old patient complaining of chest pain was admitted at our clinic due to acute anterior STEMI. He has a previous medical history of ischemic stroke, COVID-19 infection, and PE in the past 2 months. Newly, diagnosed lung adenocarcinoma was confirmed by biopsy 10 days before STEMI admission, without surgical or previous hemotherapy. The patient was on regular anticoagulant therapy with rivaroxaban 20 mg OAD and antiplatelet therapy with Aspirin due to previous PE and ischemic stroke. Patient denied standard risk factors, family history for cardiovascular disease or any previous minor or major bleedings, history of anemia, liver, or renal dysfunction. Acute stroke was confirmed by brain computed tomography imaging. Thrombophilia panel testing revealed homozygote mutations for MTHFR 677 gene, heterozygote mutation for integrin subunit alpha 2, and fibrinogen B beta chain) genes. The patient was treated with low molecular weight heparin, aspirin, clopidogrel, and heart failure therapy in the acute phase. Clinical consultations were performed with a team of doctors which included a cardiologist, neurologist, and oncologist. Patients have a high bleeding risk, assessed by HAS-BLEED score of 4. CONCLUSION: Our patient is a rare case of serious multi-vascular thrombotic events with underlying thrombophilia, lung cancer, and past COVID-19 infection complicated by pulmonary embolism, ischemic stroke, and STEMI.

Abstract 17883: Subacute Native Aortic and Mitral Valve Endocarditis Manifesting as Embolic ST-Elevation Myocardial Infarction

Case description: A 54-year-old male presented with one day of substernal chest pain. He also reported two months of malaise, myalgias, chills, and intermittent fevers. Medical history was notable for well-controlled hypertension and negative for dyslipidemia, diabetes, or drug and tobacco use. Family history was negative for premature coronary artery disease. Vitals were notable for fever of 103F, blood pressure of 108/56 mmHg, and heart rate of 88 beats per minute. Physical exam showed bounding pulses and a soft diastolic murmur at the left lower sternal border. Electrocardiogram showed inferior lead ST-elevations. He was taken for cardiac catheterization and found to have a totally occlusive thrombus in the distal right coronary artery with minimal disease in the remaining vessels. He underwent aspiration thrombectomy and placement of drug eluting stent with normal flow. He was transferred to the coronary intensive care unit. Labs showed mild leukocytosis, normal serum creatinine, and unremarkable urinalysis. Echocardiogram showed a 1.7 x 0.5 cm mobile echodensity on the aortic valve with severe aortic regurgitation and a small echodensity on the anterior mitral leaflet. Blood cultures grew Enterococcus faecalis. A CT scan of the head, chest, abdomen, and pelvis revealed no embolic disease. He underwent urgent surgery due to concern for infective endocarditis with coronary embolism. Purulence was found at the stent site and the posterior descending artery was obliterated by necrotic tissue. A bypass graft was placed distal to the stent site and infected territory was unroofed and irrigated. Mitral and aortic valve replacement was performed. He tolerated surgery and was discharged with 6 weeks of intravenous antibiotics. Discussion: This case was unique in the subacute chronicity of endocarditis and lack of other systemic emboli. Clinically relevant coronary embolism was reported in only 1.5% of cases of infective endocarditis but microemboli were found in 60% postmortem. Embolization is more common with mitral valve involvement, &gt;10 mm vegetation, and fungal or staphylococcal disease. Angiographic evidence of heavy thrombus burden or lack of significant atherosclerosis after myocardial infarction may prompt evaluation for coronary embolism.

Coronavirus disease 2019 (COVID-19) related stroke incidence: a case series

Coronavirus disease 2019 (COVID-19) can cause systemic and respiratory symptoms. Acute respiratory distress syndrome (ARDS), anemia, acute heart injury, secondary infection, and stroke are the complications of COVID-19. Age, oxidative stress, endothelial dysfunction, inflammatory status, vascular risk factors, and hypoxemia are risk factors for stroke associated with COVID-19. In this case report, two cases of COVID-19 complicated by stroke and other thromboembolic diseases were discussed. Case 1: a 46-year-old man presented with right extremities weakness, dysarthria, cough, colds, chest pain radiating to left upper extremity. He was diagnosed with moderate COVID-19, with complication of embolic stroke and myocardial infarction. After administration of IV furosemid and recombinant tissue plasminogen activator (rTPA), his condition improved, and he was discharged from our facility. Case 2: a 54-year-old woman presented with a decreased level of consciousness, skin discoloration, tenderness on her left calf, cough, fever, and shortness of breath. She was diagnosed with moderate COVID-19 with a complication of thrombotic stoke and deep vein thrombosis (DVT). She was treated with rTPA, IV citicoline, and fondaparinux for 5 days. In conclusion, COVID-19 carries a risk of thromboembolic complication. COVID-19 patients have a higher risk of bleeding, therefore, medications, particularly anticoagulant, should be administered with more caution.

Cutaneous lupus erythematosus is associated with an increased risk of cardiac and vascular diseases: a large-scale, propensity-matched global retrospective cohort study.

Autoimmune skin diseases can expedite various systemic sequelae involving other organs. Although limited to the skin, cutaneous lupus erythematosus (CLE) was noted to be associated with thromboembolic diseases. However, small cohort sizes, partially discrepant outcomes, missing data on CLE subtypes, and incomplete risk assessment limits these findings. The Global Collaborative Network of TriNetX provides access to medical records of more than 120 million patients worldwide. We used TriNetX to elucidate the risk for cardiac and vascular diseases after diagnosis of CLE, and its subtypes chronic discoid (DLE) and subacute cutaneous lupus erythematosus (SCLE). We included 30,315 CLE, 27,427 DLE, and 1613 SCLE patients. We performed propensity-matched cohort studies determining the risk to develop cardiac and vascular diseases (ICD10CM:I00-99) following diagnosis of CLE, DLE, or SCLE. Patients with systemic lupus erythematosus were excluded. We document that CLE and its subtype DLE but less so SCLE are associated with a higher risk for various cardiac and vascular diseases. This included predominantly thromboembolic events such as pulmonary embolism, cerebral infarction, and acute myocardial infarction, but also peripheral vascular disease and pericarditis. For example, the hazard ratio of arterial embolism and thrombosis was 1.399 (confidence interval: 1.230-1.591, p<0.0001) following CLE diagnosis. The study is limited by retrospective data collection and reliance on ICD10-disease classification. CLE and its major subtype DLE are associated with an increased risk for the development of a wide range of cardiac and vascular diseases. This research was funded by Deutsche Forschungsgemeinschaft (EXC 2167, CSSL/CS01-2022) and the Excellence-Chair Program of the State of Schleswig-Holstein.

Role of Recombinant Activated FVII in Severe Post‐Partum Haemorrhage

In Pakistan, improvement of health care structure and evolution of perinatal care, have led to momentous drop in pregnancy related deaths, however obstetrical haemorrhage maintains to be the principal cause of maternal motility. The aim of this study was to probe the utilization of activated, and recombinant, Factor VII (rFVIIa) in cases of severe postpartum haemorrhage (PPH). This study was carried out at Unit 2 of Obstetrics &amp; Gynaecology Department of Sir Ganga Ram Hospital (Fatima Jinnah Medical University), Lahore, over a period of 10 weeks, from 15/01/2023, to 31/03/2023. Fifteen females with severe PPH who were treated with rFVIIa were included in this study. The overall observed median and mean blood loss were 8639 mL and 11835 mL respectively. The management prior to rFVIIa involved trans-arterial embolization in five patients, while three of them had hysterectomy. One patient had one single dose, two of them had two doses, three of those patients had four doses, two patients had five plus doses, and a single patient had twenty plus doses of rFVIIa. The mean (± SD) of single dose was at 81.60 ± 16.25 µg/kg. Fourteen of those females could survive, however one of them died due to complication. The cause of that death was uterine rupture, and the quantum of haemorrhage in that case of death, was 6428–43 810 mL. This may, therefore, lead us to conclude that, irrespective of the fact whether a patient would survive or otherwise, much dependents upon her general health and proceeding rFVIIa infusion, rather than haemorrhage. Four of those females presented thromboembolic events post rFVIIa management deep vein thrombosis (DVT), DVT plus pulmonary embolism (PE), PE and acute myocardial infarction (MI). This study revealed that rFVIIa infusion had promising effects for severe PPH and markedly reduced the maternal motility. Keywords: Post-Partum Haemorrhage, Hystectomy, rFVIIa, thromboembolism

Risk of acute myocardial infarction, stroke, and venous thromboembolism among patients with anti-neutrophil cytoplasmic antibody-associated vasculitis in South Korea: A nationwide population-based study.

To investigate the incidence and risk of cerebro-cardiovascular comorbidities (stroke, acute myocardial infarction, venous thromboembolism, and pulmonary embolism) in anti-neutrophil cytoplasmic antibody-associated vasculitis using nationwide Korean population-based medical claims data. We identified 1905 patients with newly diagnosed anti-neutrophil cytoplasmic antibody-associated vasculitis during 2009-2019. Incidence rates and hazard ratios with 95% confidence intervals were calculated to estimate the risk of cerebro-cardiovascular comorbidities in these patients and compared to age- and sex-matched controls (1:10) using the Cox proportional hazards model. Most patients had microscopic polyangiitis (42.5%), followed by granulomatosis with polyangiitis (29.1%) and eosinophilic granulomatosis with polyangiitis (28.4%). The annual incidence rate of anti-neutrophil cytoplasmic antibody-associated vasculitis in 2019 was 0.55 per 100,000 person-years. Cerebro-cardiovascular comorbidities occurred in 12.6%. Stroke was most common (64.6%), followed by venous thromboembolism (34.6%), pulmonary embolism (18.3%), and acute myocardial infarction (5.4%). Korean patients with anti-neutrophil cytoplasmic antibody-associated vasculitis were at a significantly (2.3 times) higher overall risk for cerebro-cardiovascular comorbidities than the general population (adjusted hazard ratios, 4.5, 3.1, and 2.0 times higher for pulmonary embolism, venous thromboembolism, and stroke, respectively). These findings were similar for patients with each subtype of anti-neutrophil cytoplasmic antibody-associated vasculitis. This is the first nationwide population-based study to demonstrate a significant risk of cerebro-cardiovascular comorbidities as complications of anti-neutrophil cytoplasmic antibody-associated vasculitis in Korean patients. Knowing these risks may enable personalized patient care and improve overall survival.

Embolic myocardial infarction associated with patent foramen ovale: a case series

A patent foramen ovale (PFO) is a fairly common mild cardiac defect that causes a shunting across the atrial septum. PFO is also a known risk factor for cryptogenic stroke. Much less frequently, PFO is associated with non-cerebral systemic embolic events. The article describes a case series of paradoxical embolism of the coronary arteries (CA), which caused myocardial infarction (MI). The presence of PFO was confirmed by imaging techniques. Subsequently, the patients underwent successful endovascular closure of the PFO. Thus, paradoxical CA embolism is a rare and underdiagnosed cause of acute MI. It should be considered in patients with MI and a low risk of atherosclerotic coronary artery disease. However, in most cases, it is not possible to verify the source of the embolism. The significance of occluder implantation as one of the treatment tactics requires further clarification.

A singular case of embolic inferior ST-elevation myocardial infarction 40 years after surgical closure of a right coronary to right atrium fistula.

A singular case of embolic inferior ST-elevation myocardial infarction 40 years after surgical closure of a right coronary to right atrium fistula.

Incidence of Coronary Embolism in Group of Patients with Atrial Fibrillation and Myocardial Infarction

Embolic myocardial infarction (EMI) is more common than gets to be diagnosed. EMI is often associated with atrial fibrillation (AF). The incidence of this pathology, prognosis and treatment tactics remain unclear.&#x0D; AIM: To assess the incidence of EMI among patients with myocardial infarction (MI), genesis of coronary embolism (CE), initial characteristics, treatment and prognosis in group of patients with EMI.&#x0D; MATERIALS AND METHODS: The group of patients with EMI was selected among 1989 patients with MI admitted to the cardiology department of the North-Western State Medical University named after I.I. Mechnikov between 2013 to December 2019. The CE verification criteria were the SUITA criteria. Statistical data processing was carried out using the SAS program.&#x0D; RESULTS: 16 cases of EMI were registered (0.8% of all MI and 4.3% of patients with MI and AF). 68.7% (95% CI = 41.5%88.9%) of patients with EMI had AF. All patients with EMI and AF did not have adequate anticoagulant therapy before admission. Among patients with EMI, men predominated, they were younger, had fewer comorbidities than patients with MI and without AF. 13 of 16 patients with EMI were prescribed anticoagulants. During hospitalization, the composite endpoint (pulmonary embolism + stroke + cardiovascular death) was recorded in 25% (95% CI = 7.3%52.2%), in the long-term period in 30% of cases (95 % CI = 6.765.2). All these patients had AF. EMI in patients with AF was associated with the development of severe chronic heart failure (CHF) by the time of discharge and with decompensation of CHF in the long-term period.&#x0D; CONCLUSIONS: EMI often occur in group of patients with AF, always in the absence of adequate anticoagulant therapy. Patients with EMI and AF have a worse prognosis due to recurrent thromboembolic events.&#x0D; Keywords: anticoagulants; atrial fibrillation; coronary embolism; embolic myocardial infarction; prognosis; thrombaspiration.

300. Trends in electrocardiographic and cardiovascular manifestations of patients hospitalized with COVID-19

Abstract Background Early in the coronavirus disease 2019 (COVID-19) pandemic, a low incidence of cardiovascular complications was reported amongst hospitalised patients with COVID-19 in Singapore. Little was known about the trend of cardiovascular complications as the pandemic progressed. As such, we sought to examine the evolving trends in electrocardiographic and cardiovascular manifestations in patients hospitalised for COVID-19 infection. Methods We examined the first 1781 consecutive hospitalised patients with polymerase chain reaction (PCR) confirmed COVID-19 in a tertiary academic centre. We divided the population based on those who had an abnormal electrocardiogram (ECG) and those who had a normal ECG, comparing the baseline characteristics and outcomes between the 2 groups. Cardiovascular complications such as acute myocardial infarction, stroke, pulmonary embolism, myocarditis and mortality were also examined over time. Results Of the 261 (14.7%) patients presenting with abnormal ECG, they were more likely to be symptomatic with complaints of breathlessness, palpitations and chest pain. Sinus tachycardia was the most common arrhythmia. Troponin I levels (41.6±264.3 vs 97.0±482.9, p=0.047) and C-reactive protein levels (20.1±50.7 vs 13.9±24.1 µmol/L, p=0.003) were significantly higher amongst those with abnormal ECGs at presentation, with a higher prevalence of myocarditis (1.9% vs 0.5%, p=0.021), pulmonary embolism (1.9% vs 0.3%, p=0.009) and acute myocardial infarction (1.1% vs 0.1%, p=0.025). Over time, there was a trend towards a higher proportion of hospitalised patients with cardiovascular complications. Baseline characteristics of hospitalised patients with COVID-19, with or without abnormal ECG at presentation Changes in percentage of hospitalised patients with COVID-19, experiencing cardiovascular events (acute myocardial infarction, stroke, myocarditis, pulmonary embolism and death) over time Conclusion A baseline ECG at presentation is a simple test that provides valuable information on potential cardiovascular complications in the context of COVID-19. Although the prevalence of abnormal ECGs is relatively low, it appears to be increasing over time amongst hospitalised patients with COVID-19. Disclosures All Authors: No reported disclosures.

Concomitant Pulmonary Embolism and Anterior Myocardial Infarction as the Initial Presentation of Antiphospholipid Syndrome

Antiphospholipid antibody syndrome (APLS) is a systematic autoimmune disease characterized by thrombotic events, including arterial, venous, and microvascular complications. Often, patients initially present with either arterial or venous thromboembolism but rarely present simultaneously with arterial and venous thromboembolic events.1Garcia D. Erkan D. Diagnosis and management of the antiphospholipid syndrome.N Engl J Med. 2018; 378: 2010-2021https://doi.org/10.1056/NEJMra1705454Crossref PubMed Scopus (321) Google Scholar We report an unusual case of a 21-year-old woman who presented to our hospital with chest pressure secondary to a concomitant pulmonary embolism (PE) and anterior myocardial infarction. A 21-year-old woman with no significant past medical history, only on oral contraceptive pills, presented to the hospital with complaints of 4 days of progressively worsening substernal chest pressure associated with dizziness and lightheadedness. In the emergency department, she was mildly tachycardic but otherwise hemodynamically stable. An electrocardiogram revealed sinus rhythm with anterior T-wave abnormality (Figure 1A). Initial laboratory testing revealed mild thrombocytopenia and elevated troponin I levels of 9.63 ng/mL. A computed tomography angiography of the chest revealed small nonocclusive emboli in the right lower lobe pulmonary artery (Figure 1B); therefore, venous duplex ultrasound of the lower extremities was performed, which showed no evidence of deep vein thrombosis. Anticoagulation with intravenous heparin was started, and the patient was admitted to the floor with telemetry monitoring. Early morning on day 2 of hospitalization, the patient reported worsening chest pain, and the troponin I levels subsequently trended up to 20.08 ng/mL. A repeat electrocardiogram showed subtle ST-segment elevations, with QS complexes in the anterior leads. A bedside transthoracic echocardiogram revealed hypokinesis of the anterior wall and a severely reduced left ventricular ejection fraction. The patient was transferred to the cardiac catheterization laboratory for emergency coronary angiography. Coronary angiography showed 100% occlusion of the left anterior descending artery (LAD) at the ostium. The right coronary artery was patent with extensive right to left collaterals supplying the LAD. A filling defect was noted in the proximal LAD, consistent with a thrombus. Thrombus aspiration was performed using the Indigo System CAT RX (Penumbra, Inc), followed by the placement of a single 3.0 × 18 mm XIENCE Skypoint (Abbott) drug-eluting stent in the proximal LAD, with resultant TIMI-3 flow. A formal transthoracic echocardiogram demonstrated a left ventricular ejection fraction of 35%-40%, with a large left ventricular thrombus. Subsequent testing revealed antibody positivity for APLS, with elevated titers of anticardiolipin, lupus anticoagulant, and beta-2-glycoprotein antibodies. The patient was discharged on aspirin, ticagrelor, and warfarin along with high-intensity statin therapy, a low-dose angiotensin-converting enzyme inhibitor, and β-blocker therapy. The patient’s oral contraceptive pills were discontinued, and the patient was counseled about the use of an alternative nonhormonal mode of contraception. Approximately 12 weeks after discharge, the patient’s outpatient laboratory reports showed persistent elevation of all 3 antibodies, thus establishing the diagnosis of triple-positive APLS. Massive or submassive PEs can cause acute right heart strain and result in a small elevation of troponin levels. However, a high initial troponin level in patients with a nonmassive PE should raise suspicion of acute coronary syndrome, even with a low pretest probability of acute coronary syndrome.2Meyer T. Binder L. Hruska N. Luthe H. Buchwald A.B. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction.J Am Coll Cardiol. 2000; 36: 1632-1636https://doi.org/10.1016/S0735-1097(00)00905-0Crossref PubMed Scopus (277) Google Scholar,3Kilinc G. Dogan O.T. Berk S. Epozturk K. Ozsahin S.L. Akkurt I. Significance of serum cardiac troponin I levels in pulmonary embolism.J Thorac Dis. 2012; 4: 588-593https://doi.org/10.3978/j.issn.2072-1439.2012.10.13Crossref PubMed Scopus (15) Google Scholar Therefore, the detection of a high initial troponin level should be followed by serial troponin level testing and electrocardiograms, an echocardiogram, and an ischemic evaluation. Patients with APLS may present with complications of arterial or venous thromboembolism; however, they rarely present with both simultaneously. Myocardial infarction and PE associated with APLS have been extensively reported in the literature; however, there are limited reports regarding the incidence of simultaneous events as the initial presentation of APLS.4Nazir S. Tachamo N. Lohani S. Hingorani R. Poudel D.R. Donato A. Acute myocardial infarction and antiphospholipid antibody syndrome: a systematic review.Coron Artery Dis. 2017; 28: 332-335https://doi.org/10.1097/MCA.0000000000000476Crossref PubMed Scopus (32) Google Scholar A high index of suspicion should be maintained for APLS in young patients presenting with concomitant arterial and venous thromboembolic events because the timely diagnosis and initiation of anticoagulation can prevent further thromboembolic complications. Further research is required regarding optimal anticoagulation strategies after percutaneous coronary interventions in patients with hypercoagulation disorders. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Bleeding and thrombotic complications in patients with severe COVID-19: A prospective observational study.

Bleeding and thrombotic complications in patients with severe COVID-19: A prospective observational study.

Differential diagnosis of intraoperative cardiac arrest after spine surgery in prone position

Intraoperative cardiac arrest is one of the most feared events by anesthesiologists and surgeons. Although there are many possible causes, three differential diagnoses stand out in the presented scenario: pulmonary embolism, gas embolism, and acute myocardial infarction. A 61-year-old female patient was admitted in the hospital to C2-C5 arthrodesis. Despite no major bleeding during surgery, immediately after supination the patient developed refractory hypotension, a decrease in end tidal CO2, progressive bradycardia that ultimately led to pulseless electrical activity. Resuscitation maneuvers were promptly performed, sustained return of spontaneous circulation was attained after 50 minutes, and the patient was transferred to the ICU. This paper discusses the main causes for an episode of cardiac arrest in the context of cervical arthrodesis, with a markedly prolonged resuscitation time, in which the patient survived.

Acute Myocardial Infarction after Intravenous Thrombolysis for Acute Ischemic Stroke: Case Series and Systematic Review

Background and objectivesIntravenous thrombolysis (IV–rtPA) has been suggested as a potential cause of myocardial infarction (MI) after acute ischemic stroke (AIS), with randomized clinical trials showing a higher number of cardiac events within the thrombolysis group. We assessed the prevalence and MI mechanisms after IV–rtPA for AIS. MethodsRetrospective review of consecutive AIS patients admitted to six stroke units and systematic literature review searching for AIS patients who suffered a MI less than 24 h after IV–rtPA. In those with available coronary angiography, MI etiology was defined as atherosclerotic or embolic. Patients’ characteristics were compared between groups. ResultsFifty-two patients were included. Thirty-two patients (61.5%) derived from hospital cases, after reviewing 6958 patients treated with IV–rtPA [0.5% (95% CI 0.38–0.54) of total hospital cases]. After coronary angiography (n = 25, 48.1%), 14 (54%) patients were considered to have an atherosclerotic MI, and 11 (46%) due to coronary embolism. Patients with an embolic MI more frequently had a cardioembolic AIS (72.7% vs 28.6%; p-value = 0.047) and an intracardiac thrombus (27.3% vs 0.0%; p-value = 0.044). Although not statistically significant, patients with an embolic MI had apparent lower time intervals between starting IV–rtPA infusion and MI occurrence [2 h (0.2–3.0) vs 3 h (1.0–15.0); p-value = 0.134]. ConclusionsMI within the first 24 h after IV–rtPA for AIS is an infrequent event, and more frequently non-embolic. However, the prevalence of embolic MI was superior to what is found in the general population with MI. There was an association between the pathophysiology of AIS and MI. The low number of events and publication bias may have limited our conclusions.