Myocardial infarction and embolism: a rare combination associated with a poor prognosis (a clinical case)

The article describes a clinical case of a 44-year-old woman with almost simultaneous onset of massive pulmonary embolism (bilateral involvement) secondary to posterior tibial vein thrombosis with a floating thrombus, and embolic myocardial infarction caused by paradoxical embolism through an atrial septal defect. These events occurred against a background of severe anemia of unknown etiology. The management strategy initial primary percutaneous coronary intervention for type 2 myocardial infarction and thrombotic occlusion of the posterior interventricular artery with stent implantation, and subsequent thrombolytic therapy for pulmonary embolism. The article further discusses the complex issues of prescribing and adjusting antithrombotic therapy based on decisions by medical council, which led to significant clinical improvement by the time of the patient’s discharge.

1. Danilov AV, Kobzar II, Nagibin OA, et al. Morbidity and mortality from cardiovascular diseases in Ryazan district: 2014-2018. Science of the young (Eruditio Juvenium). 2019;7(3):439-49 (In Russ.) DOI:10.23888/HMJ201973439-449.

2. Yakushin SS, Nikulina NN, Terekhovskaya YV. Clinical Manifestations and Diagnosis of Pulmonary Embolism in Routine Clinical Practice: Data from the Ryazan Regional Vascular Center. I.P. Pavlov Russian Medical Biological Herald. 2022;30(1):51-62 (In Russ.) DOI:10.17816/PAVLOVJ85405.

3. Mridha N, Ward E, Hayman S, et al. Paradoxical embolism through patent foramen ovale as a cause of myocardial infarction. Med J Aust. 2021;215(2):68-9. e1. DOI:10.5694/mja2.51140.

4. Kleber FX, Hauschild T, Schulz A, et al. Epidemiology of Myocardial Infarction Caused by Presumed Paradoxical Embolism via a Patent Foramen Ovale. Circ J. 2017;81(10):1484-9. DOI:10.1253/circj.CJ-16-0995.

5. Thygesen K, Alpert JS, Jaffe AS, et al; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/ American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). Glob Heart. 2018;13(4):305-38. DOI:10.1016/j.gheart.2018.08.004.

6. Liu Y, Yang Z, Sun X, et al. Successful surgical treatment of impending paradoxical embolism with pulmonary embolism and myocardial infarction. J Cardiothorac Surg. 2024;19(1):137. DOI:10.1186/s13019-024-02606-0.

7. Koutroulou I, Tsivgoulis G, Tsalikakis D, et al. Epidemiology of Patent Foramen Ovale in General Population and in Stroke Patients: A Narrative Review. Front Neurol. 2020;11:281. DOI:10.3389/fneur.2020.00281.

8. Ioannidis SG, Mitsias PD. Patent Foramen Ovale in Cryptogenic Ischemic Stroke: Direct Cause, Risk Factor, or Incidental Finding? Front Neurol. 2020;11:567. DOI:10.3389/fneur.2020.00567.

9. Ezeh E, Katabi A, Khawaja I. Iron Deficiency Anemia as a Rare Risk Factor for Recurrent Pulmonary Embolism and Deep Vein Thrombosis. Cureus. 2021;13(3):e13721. DOI:10.7759/cureus.13721.

10. Kakkos SK, Gohel M, Baekgaard N, et al. Editor’s Choice — European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg. 2021;61(1):9-82. DOI:10.1016/j.ejvs.2020.09.023.

11. Panchenko EP, Balahonova TV, Danilov NM, et al. Diagnosis and Management of pulmonary embolism: Eurasian Association of Cardiology (EAC) Clinical Practice Guidelines (2021). Eurasian heart journal. 2021;(1):44-77 (In Russ.) DOI:10.38109/2225-1685-2021-1-44-77.

12. Alkhalil M, Cahill TJ, Boardman H, Choudhury RP. Concomitant pulmonary embolism and myocardial infarction due to paradoxical embolism across a patent foramen ovale: a case report. Eur Heart J Case Rep. 2017;1(2):ytx010. DOI:10.1093/ehjcr/ytx010.

13. Hline A, Malik N, Khokhar A, Aggarwal R. Acute myocardial infarction caused by paradoxical embolism with concomitant pulmonary embolism. BMJ Case Rep. 2011;2011:bcr0320113953. DOI:10.1136/bcr.03.2011.3953.

14. Maharaj V, Velangi PS, Prins K, et al. Double Rule In: Concomitant Acute Coronary Occlusion and Pulmonary Embolism. JACC Case Rep. 2019;1(4):669-70. DOI:10.1016/j.jaccas.2019.08.021.