Coronary Embolism Triggers Acute Myocardial Infarction in Takotsubo Cardiomyopathy Patient
A 74-year-old woman with a history of chronic obstructive pulmonary disease, tobacco use disorder, dyslipidemia, generalized anxiety disorder, unprovoked deep vein thrombosis, and pulmonary embolism presented to the emergency department with acute chest pain and shortness of breath just days after holding her apixaban for laser cataract surgery.
Plain English Guide to This Vascular Event
- Takotsubo Cardiomyopathy: A temporary weakening of the heart muscle, often triggered by physical or emotional stress, causing the main pumping chamber to balloon outward.
- Coronary Embolism: A blood clot that travels through the bloodstream and blocks a coronary artery, cutting off oxygen to the heart muscle.
- Left Ventricular Mural Thrombus: A blood clot that forms along the inner wall of the heart’s main pumping chamber due to sluggish blood flow.
Surgical Interventions and Clinical Findings on Admission
The patient presented with acute-onset chest pain lasting 2 days following a laser cataract procedure for which her apixaban had been held for 3 days. Her vital signs were within normal limits upon arrival, but initial diagnostic testing revealed severe cardiac distress. An electrocardiogram showed ST elevation and pathologic Q waves in the inferior and anterolateral leads, consistent with an ST-elevation myocardial infarction. Her initial troponin measured 5827 ng/L, far above the normal threshold of less than 14 ng/L, while B-type natriuretic peptide reached 10,861 pg/mL against a normal ceiling of 100 pg/mL.
Reverse Takotsubo cardiomyopathy is rare (~2% of cases) and can mimic acute coronary syndrome.This case describes a 27-year-old woman developing cardiogenic shock during Caesarean section under epidural anaesthesia, with rapid recovery of LV function after supportive therapy.… pic.twitter.com/PBaJIaJvXc
Urgent cardiac catheterization uncovered an embolus with two truncations in the distal obtuse marginal 1 branch. Physicians performed balloon angioplasty and thrombectomy without finding evidence of atherosclerotic obstructive coronary disease. Intraoperative treatment included a loading dose of tirofiban and clopidogrel alongside a single dose of intravenous furosemide. Subsequent coronary angiography confirmed the complete resolution of the obstruction in the target branch.
| Diagnostic Test | Patient Result | Normal Reference Range |
|---|---|---|
| Initial Troponin | 5827 ng/L | < 14 ng/L |
| B-type Natriuretic Peptide | 10,861 pg/mL | < 100 pg/mL |
Multidisciplinary Management and Post-Procedural Care
The transthoracic ECG displayed classic features of takotsubo cardiomyopathy, characterized by basal hyperdynamic motion and ballooning of the apex and anterior wall alongside a left ventricular mural thrombus. Boran Mao, MD, of the Internal Medicine department at the University of Central Florida College of Medicine in Orlando, and colleagues documented the case. After ruling out pulmonary embolism via a computed tomography pulmonary angiogram, clinicians re-initiated apixaban within 24 hours of the procedure.
The patient was discharged on a comprehensive medical regimen combining dual antiplatelet therapy consisting of 81 mg of aspirin daily and 75 mg of clopidogrel daily, paired with apixaban at 5 mg twice daily. Guideline-directed medical therapy included valsartan 24 mg twice daily, sacubitril 26 mg twice daily, and carvedilol 6.25 mg twice daily. She was also fitted with a wearable defibrillator vest upon discharge.
Contraindications & When to Consult a Doctor
Patients with a history of unprovoked deep vein thrombosis and pulmonary embolism who require temporary cessation of direct oral anticoagulants like apixaban for surgical procedures face distinct thromboembolic vulnerabilities. Abrupt discontinuation of anticoagulation therapy in the presence of severe left ventricular dysfunction demands careful perioperative risk stratification. Individuals experiencing acute-onset persistent chest pain, sudden shortness of breath, or palpitations following recent surgery or cardiovascular stress must seek immediate emergency medical evaluation.
