Joseph Marc S. Seguban MD,
Elaine Alajar MD, Jessore Isidro MD, Noemi Pestaño MD,
Felix Eduardo Punzalan, MD and Bernadette Tumanan-Mendoza, MD****

ABSTRACT

Introduction: Pulmonary embolism and myocardial infarction are the leading causes of cardiovascular death worldwide. The coexistence of these vascular conditions can occur with high morbidity and mortalityifnotpromptlyrecognizedandadequatelymanaged.
Case presentation: A case of a 67-year-old male hypertensive smoker, with a history of previous myocardial infarction who had intra-operative bleeding requiring multiple blood transfusions during radical prostatectomy for Stage II Prostate Carcinoma presented with shortness of breath, syncope and chest pain. His electrocardiogram revealed an anterior wall ST elevation Myocardial Infarction while his echocardiogram showed left ventricular segmental hypokinesia consistent with coronary artery disease, with incidental right atrial thrombus and right ventricular dysfunction. Given these findings, pulmonary embolism was also entertained. Compression ultrasound of the lower extremities revealed a left popliteal vein thrombosis. Immediate coronary angiography showed left main coronary and left anterior descending artery stenosis for which angioplasty with stenting was performed. Subsequent pulmonary angiography showed filling defects in the main pulmonary arteries consistent with pulmonary embolism. Further evaluation using computed tomography pulmonary angiography defined the extent of pulmonary embolism with concomitant thrombus at the superior vena cava. Despite the coronary intervention, his dyspnea persisted even at rest, thus intravenous tissue plasminogen (tPA) activator was administered at a reduced dose (50mg for 2 hours) due to high risk of bleeding. He was stable during and after the thrombolytic infusion and was discharged improved on Ticagrelor, Aspirin and Enoxaparin
Diagnosis and treatment outcome: This case documents the rare occurrence of both MPE and AMI in a patient with high bleeding risk. On 3 months’ follow-up, the patient was in NYHA functional class I with a Borg dyspnea scale of 6. A repeat echocardiogram showed improvement of left ventricular wall motion and systolic function as well the resolution of the right atrial thrombus and right ventricular dysfunction indicating successful management of the case.
Conclusion: Considering concurrent MPE and AMI can occur, validated prediction scoring and appropriate diagnostics must be utilized for accurate diagnosis and management. Bleeding risk assessment is of importance in treatment selection. This case suggests that a low dose tPA may be considered for certain patients, particularly if there are significant bleeding risks.

*****Advisers/Consultants, Department of Internal Medicine Section of Cardiology