A case of coronary embolism in a patient with paroxysmal atrial fibrillation receiving tamoxifen

A Ghost in Coronary Artery - Coronary Artery Embolism After Discontinuation of Rivaroxaban in a Patient With Atrial Fibrillation: Case Report and Review of Literature

Coronary artery embolism (CAE) is a rare clinical entity that can cause acute myocardial infarction (AMI). The exact prevalence of coronary artery embolism is unknown. CAE was found to be associated with conditions that can lead to thrombo-embolism, including infective endocarditis, atrial fibrillation, mitral valve disease, valve surgery. Herein, we report a 78-year-old male with a past medical history of atrial fibrillation on rivaroxaban who presented to the hospital emergency department complaining of chest pain. The patient's anticoagulation therapy was recently held due to a concern for gastrointestinal bleeding. After further evaluation of the patient's symptoms and reviewing his electrocardiogram (ECG) which showed ST-depression in lateral leads and ST-elevation in aVR, urgent cardiac catheterization was done which showed left main coronary artery thrombosis extending into the left anterior descending artery (LAD) and left circumflex artery (LCX). The patient was started on a heparin drip and underwent a successful aspiration thrombectomy with subsequent improvement in his symptoms.

Saddle coronary embolism precipitates flash pulmonary edema

Coronary artery embolism is as an infrequent but important cause of acute myocardial infarction. We present a rare case of a large saddle embolism in the coronary vasculature which led to an acute myocardial infarction and consequently flash pulmonary edema. Despite intensive medical management, our patient did not survive.

Coronary Embolism and Myocardial Infarction: A Scoping Study

Coronary embolism is a cause of acute myocardial infarction (AMI)in which obstructive foci enter the coronary circulation, block normal blood flow and precipitate ischemia. Precise studies focusing on patient population affected, pathophysiological mechanisms, and treatment strategies are scanty, in spite of a reported prevalence estimated at 2.9%. As the understanding of myocardial infarction without evidence of coronary artery disease continues to grow, an in-depth review of this previously seldomly reported subtype of coronary ischemia was in order. Patients suffering coronary embolism are 15 to 20 years younger than traditional AMI patients with a slight predominance towards male sex, which resembles the gender data of the populations affected by non-traditional myocardial infarction in published reports. While the expected prevalence rate of cardiovascular disease risk factors such as hypertension and hyperlipidemia are present, this population also has a relatively high prevalence of atrial fibrillation and valve pathology, especially endocarditis. Initial presentation is indistinguishable from other causes of myocardial infarction however fever is commonly present, when endocarditis with valvular involvement is the primary cause of the coronary embolism. Mechanical thrombectomy is the mainstay of treatment, followed by percutaneous coronary intervention. Mortality is the highest in patients who do not receive targeted treatment for the coronary embolism, particularly if only antimicrobial agents or anticoagulation without thrombolytic agents are employed. The unique features of coronary embolism highlighted in this historical study justify further examination in contemporary patient populations.

Acute Coronary Syndrome (ACS) due to Coronary Artery Embolism in a Patient with Atrial Fibrillation

Acute coronary syndrome (ACS) secondary to a coronary embolism is an unusual occurrence, yet an important consideration given the difficult diagnosis. We report a case of a 69-year-old male with a medical history of paroxysmal atrial fibrillation who presented with chest pain and shortness of breath. A coronary angiogram was significant for three focal transluminal and translucent areas in the ostial, mid, and distal circumflex artery consistent with embolic disease. The patient was subsequently managed medically with anticoagulation. Despite being a relatively rare entity, thromboembolism into the coronary arteries can provoke an acute myocardial infarction, with atrial fibrillation being the most common risk factor. Treatment modalities for ACS secondary to thromboembolism include stent placement, intracoronary thrombolysis, and thrombus aspiration.

Coronary Embolism: A Systematic Review

BACKGROUND

Coronary embolism is a rare and potentially fatal phenomenon that occurs primarily in patients with valvular heart disease and atrial fibrillation. There is a lack of consensus regarding the diagnosis, treatment, and management of coronary embolism, leaving management at the discretion of the treating physician. Through this review, we aim to establish a better understanding of coronary embolism, and to identify treatment options - invasive and non-invasive - that may be used to manage coronary embolism.

METHODS AND RESULTS

Our systematic review included 147 documented cases of coronary embolism from case reports and case series. The average age of our population was 54.2 ± 17.6 years. The most common causes of coronary embolism included infective endocarditis (22.4%), atrial fibrillation (17.0%), and prosthetic heart valve thrombosis (16.3%). Initial presentation was indistinguishable from an acute coronary syndrome (ACS) due to coronary atherosclerosis, and the diagnosis required a high level of suspicion and evaluation with angiography. Treatment strategies included, but were not limited to, thrombectomy, thrombolysis, balloon angioplasty and stent placement. Myocardial dysfunction on echocardiography was observed in over 80% of patients following coronary embolism. "Good outcomes" were reported in 68.7% of case reports and case series, with a mortality rate of 12.9%.

CONCLUSION

Coronary embolism is an under-recognized etiology of myocardial infarction with the potential for significant morbidity and mortality. To improve outcomes, physicians should strive for early diagnosis and intervention based on the underlying etiology. Thrombectomy may be considered with the goal of rapid restoration of coronary flow.

A Suspected Case of Acute Embolic Myocardial Infarction Following Direct-Current Cardioversion of Atrial Fibrillation

Patient: Male, 66

Final Diagnosis: A suspected case of acute embolic myocardial infarction following direct current cardioversion of atrial fibrillation

Symptoms: Exertional shortness of breath

Medication: —

Clinical Procedure: Direct current cardioversion

Specialty: Cardiology

A fluttering coronary event

Acute coronary syndrome (ACS) is a term used to describe a spectrum of diseases associated with sudden reduced blood flow to the heart. Coronary artery thromboembolism is recognized as an important nonatherosclerotic cause of acute myocardial infarctions in 2.9% of ACS cases, with a long-term outcome indicating that coronary embolism patients represent a high-risk subpopulation. There are various risk factors for developing a coronary thromboembolism, with atrial fibrillation being the most frequently reported cause. Herein, we are presenting a case of a 65-year-old female patient who presented to the emergency department with sudden-onset pressure-like chest pain diagnosed as ACS due to nonatherosclerotic thromboembolism secondary to atrial flutter.

Tamoxifen Pharmacovigilance: Implications for Safe Use in the Future

OBJECTIVE

To survey the status of current tamoxifen pharmacovigilance documentation reflecting tamoxifen use in an academic outpatient multispecialty practice in older adults. This data will help provide information to develop improved pharmacovigilance for a growing cohort of older adult users. The data will be utilized by an interdisciplinary team developing new methods of identifying factors for individualized pharmacovigilance in older adults.

DESIGN

Retrospective chart review to gather descriptive and quantitative data on tamoxifen pharmacovigilance.

SETTING

Multi-specialty clinic.

PATIENTS

Ninety-three patients 60 years of age and older.

MAIN OUTCOME MEASURES

Quantitative report of tamoxifen monitoring as well as descriptive analysis of individual cases.

RESULTS

We found 19 cases of serious adverse events possibly related to tamoxifen (thrombi, uterine malignancies). There were 15 cases with no documentation of pharmacovigilance. All cases had incomplete pharmacovigilance documented. There were two cases of hypercalcemia. There was one case of tamoxifen discontinuation resulting from muscle pain and with chronic muscle pain complaints while receiving tamoxifen. We observed a correlation in older age or high comorbidity burden patients and adverse events patients.

CONCLUSION

Some studies direct the important pharmacovigilance toward prevention of thrombi, uterine malignancies, and hypercalcemia; however, it is not easy to identify recommendations for frequency or focus of monitoring to prevent adverse events for individual older adults based on existing recommendations. The data collected and presented in this study serve to heighten awareness of tamoxifen pharmacovigilance and as a starting point for the application of machine learning techniques and modeling to identify high-risk patients and individualized pharmacovigilance recommendations.

Prevalence, Clinical Features, and Prognosis of Acute Myocardial Infarction Attributable to Coronary Artery Embolism

BACKGROUND

Coronary artery embolism (CE) is recognized as an important nonatherosclerotic cause of acute myocardial infarction. Its prevalence, clinical features, and prognosis remain insufficiently characterized.

METHODS AND RESULTS

We screened 1776 consecutive patients who presented with de novo acute myocardial infarction between 2001 and 2013. CE was diagnosed based on criteria encompassing histological, angiographic, and other diagnostic imaging findings. The prevalence, clinical characteristics, treatment strategies, in-hospital outcomes, and long-term risk of CE recurrence or major adverse cardiac and cerebrovascular events (cardiac death, fatal arrhythmia, or recurrent thromboembolism) were evaluated. The prevalence of CE was 2.9% (n=52), including 8 (15%) patients with multivessel CE. Atrial fibrillation was the most common cause (n=38, 73%). Only 39% of patients with CE were treated with vitamin K antagonists, and the median international normalized ratio was 1.42 (range, 0.95-1.80). Eighteen of the 30 CE patients with nonvalvular atrial fibrillation had a CHADS2 score of 0 or 1. When those patients were reevaluated using CHA2DS2-VASc, 61% were reassigned to a higher risk category. During a median follow-up of 49 months, CE and thromboembolism recurred in 5 atrial fibrillation patients. The 5-year rate of major adverse cardiac and cerebrovascular events was 27.1%. In the propensity score-matched cohorts (n=45 each), Kaplan-Meier analysis showed a significantly higher incidence of cardiac death in the CE group than in the non-CE group (hazard ratio, 9.29; 95% confidence interval, 1.13-76.5; P<0.001).

CONCLUSIONS

Atrial fibrillation is the most frequent cause of CE. Patients with CE represent a high-risk subgroup of patients with acute myocardial infarction and require close follow-up.

Atrial fibrillation and the risk of myocardial infarction

IMPORTANCE

Myocardial infarction (MI) is an established risk factor for atrial fibrillation (AF). However, the extent to which AF is a risk factor for MI has not been investigated.

OBJECTIVE

To examine the risk of incident MI associated with AF.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort of 23,928 participants residing in the continental United States and without coronary heart disease at baseline were enrolled from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort between 2003 and 2007, with follow-up through December 2009.

MAIN OUTCOMES AND MEASURES

Expert-adjudicated total MI events (fatal and nonfatal).

RESULTS

Over 6.9 years of follow-up (median 4.5 years), 648 incident MI events occurred. In a sociodemographic-adjusted model, AF was associated with about 2-fold increased risk of MI (hazard ratio [HR], 1.96 [95% CI, 1.52-2.52]). This association remained significant (HR, 1.70 [95% CI, 1.26-2.30]) after further adjustment for total cholesterol, high-density lipoprotein cholesterol, smoking status, systolic blood pressure, blood pressure-lowering drugs, body mass index, diabetes, warfarin use, aspirin use, statin use, history of stroke and vascular disease, estimated glomerular filtration rate, albumin to creatinine ratio, and C-reactive protein level. In subgroup analysis, the risk of MI associated with AF was significantly higher in women (HR, 2.16 [95% CI, 1.41-3.31]) than in men (HR, 1.39 [95% CI, 0.91-2.10]) and in blacks (HR, 2.53 [95% CI, 1.67-3.86]) than in whites (HR, 1.26 [95% CI, 0.83-1.93]); for interactions, P = .03 and P = .02, respectively. On the other hand, there were no significant differences in the risk of MI associated with AF in older (≥75 years) vs younger (<75 years) participants (HR, 2.00 [95% CI, 1.16-3.35] and HR, 1.60 [95% CI, 1.11-2.30], respectively); for interaction, P = .44.

CONCLUSIONS AND RELEVANCE

AF is independently associated with an increased risk of incident MI, especially in women and blacks. These findings add to the growing concerns of the seriousness of AF as a public health burden: in addition to being a well-known risk factor for stroke, AF is also associated with increased risk of MI.

Acute myocardial infarction due to coronary artery embolus associated with atrial fibrillation

Coronary artery embolus is a rare and potentially under- recognised cause of acute myocardial infarction. We describe the case of an 80-year-old woman presenting with an acute coronary syndrome secondary to coronary artery embolus associated with atrial fibrillation, which was successfully treated with the use of a thrombectomy aspiration catheter.

Acute myocardial infarction due to coronary artery embolism in a patient with atrial fibrillation

A 66-year-old female was referred for primary coronary intervention because of acute inferior STelevation myocardial infarction. Electrocardiography also showed atrial fibrillation. Coronary angiography showed a distal occlusion of the right coronary artery. Two different wires did not pass the occlusion, but dislodged the apparent thrombus more distally. No abnormalities were seen in the course of the recanalised part of the vessel. The sequential angiographic images together with the presence of atrial fibrillation are highly suggestive of coronary embolism as the cause of the myocardial infarction. Anticoagulation and rate control strategy was initiated. The patient was discharged in good condition. (Neth Heart J 2009;17:297-9.).

Acute embolic myocardial infarction in a patient with paroxysmal atrial fibrillation receiving direct-current cardioversion

Coronary embolism with acute myocardial infarction (MI) following direct-current (DC) cardioversion of atrial fibrillation (AF) has rarely been reported. We present the case of a 34-year-old female with severe aortic regurgitation and highly symptomatic paroxysmal AF. Acute embolic MI occurred 4 days after DC cardioversion of AF, although there was no left atrial thrombus detected before this procedure. Insufficient anticoagulation therapy during the post-cardioversion period was the cause, leading to embolic MI.

[Coronary embolism: a not so rare cause of myocardial infarction? Review of the literature about five suspected cases of patients in atrial fibrillation]

Five cases of myocardial infarction suspected to be due to coronary embolism are presented. All five patients had atrial fibrillation (AF), four of them with nonvalvular AF. The literature regarding coronary embolism is reviewed; the clinical manifestations and the place of AF are discussed.