Paradoxical Coronary Artery Embolism
Description
Introduction and Abstract
Young individuals (less than 35 years old) frequently have non-cardiac chest discomfort, such as musculoskeletal, pulmonary, gastrointestinal, anxiety, or drug-related.
Although they are uncommon in this age range, cardiac causes—particularly MI—must always be taken into account.
In this case, a paradoxical embolism through a big atrial septal defect (ASD) caused an inferior ST-elevation MI (STEMI) in a 19-year-old man.
Case Study
Presentation of the patient: A 19-year-old man complained of substernal chest discomfort (8/10 severity, diffusely radiating) for three hours.
Onset: Unexpected, when at rest.
Past medical history: undiagnosed cardiac murmur from childhood.
Habits: abstaining from tobacco, occasionally using marijuana, and denying using cocaine or meth.
absence of trauma or other systemic signs in the past.
Vitals: Stable (BP 128/74, HR 58 bpm, SpO₂ 98%) during examination.
Heart exam: normal beat, 2/6 systolic murmur.
Other systems: Typical.
Investigations: CBC, chemistries, and troponin were all unremarkable in the first labs.
ECG results:
52 bpm sinus bradycardia.
Inferior STEMI is indicated by reciprocal ST depression in V1–V2 and ST-segment elevation (5 mm) in leads II, III, and aVF.
Aspirin, nitroglycerin, morphine, and heparin are administered as part of immediate care, followed by an emergent transfer for cardiac catheterisation.
Heart angiography:
RCA terminal branches are completely obscured by twin PDA branches that exhibit clotting and sudden closure.
Angioplasty, stenting, and thrombectomy were not sought because of the small calibre and distant position (risks > benefits).
began receiving an injection of eptifibatide.
Echocardiogram: Bidirectional shunting and a large secundum ASD (2.9 cm).
Hospital education:
Heart serial markers: Myoglobin = 32.5 ng/mL; peak CK = 1521 IU/L.
48 hours of monitoring revealed no arrhythmias.
released on Warfarin, Metoprolol 25 mg BID, and Aspirin 81 mg.
Surgical correction is planned since percutaneous repair is not an option.
Six weeks later: ASD was successfully repaired surgically, and the rehabilitation went smoothly.
Discussion
Coronary artery embolism as a result of paradoxical embolism through big ASD is the cause of MI.
Epidemiology of ASDs: Contributes around 7% of congenital cardiac disease; whereas big ASDs might cause difficulties, little ones (less than 6 mm) typically close on their own.
Complication mechanism: embolus bypasses the lungs by right-to-left shunting and enters the systemic circulation (in this case, the coronary arteries).
Uncommon event: Strokes, not MI, account for the majority of embolic consequences in ASD.
Diagnostic delay: a murmur that has existed from childhood but has never been looked at. ASD was only identified following MI.
Diagnostic instruments: Transesophageal and transthoracic echocardiography are useful for identifying embolic origins.
MI in individuals under 35 years of age:
Causes of atherosclerosis: Risk factors include smoking, family history, hypertension, and dyslipidaemia; it is more common in males.
Causes other than atherosclerosis:
vasospasm brought on by drugs, particularly cocaine.
Unplanned dissection of the coronary arteries (more prevalent in women).
embolism of the heart (as in this example).
Clinical significance:
Young patients' chest discomfort is frequently written off as non-cardiac.
Important lessons learnt from this case: No matter your age, get an ECG if you have chest discomfort.
Underlying pathology may be discovered with a thorough history and physical examination (e.g., heart murmur).
MI may have been avoided if ASD had been identified earlier (if murmur had been assessed sooner).
For young patients, targeted examination (ECG, CXR, echocardiography) is the most effective way to rule out significant cardiac problems.
Protocol
Management:
Due to the lack of a proven cure, pulmonary alveolar microlithiasis (PAM) poses special management and nursing care issues. Progressive respiratory insufficiency, hypoxaemia, and complications associated with chronic lung disease are the primary issues that patients face. Supportive and symptomatic interventions, including nursing strategies for preserving quality of life and averting complications, are the main focus of management.
Management Issues and Solutions
Patients with respiratory insufficiency frequently need additional home oxygen therapy to maintain appropriate saturation levels and enhance everyday functioning due to their growing hypoxaemia and dyspnoea.
Lung transplantation may be an option in refractory instances, particularly those with advanced illness; however, this is only for individuals who have substantial impairment and have not responded well to previous treatments.
No Effective Disease-Modifying Treatments:
Traditional therapies like bronchoalveolar lavage and corticosteroids have not shown any promise.
The necessity for symptomatic care is highlighted by the limited efficacy of bisphosphonate therapy (etidronate), which has been tried in certain instances to lessen calcific deposition.
Interventions in Nursing
- Administration of Oxygen Therapy: Constant observation and control of oxygen administration to treat hypoxaemia while guaranteeing that pulse oximetry readings stay within acceptable bounds.
Instruction on the usage of oxygen equipment and safety issues for the patient and their family.
- Encouraging and teaching good coughing methods and, if required, the use of incentive spirometry to maximise lung expansion and minimise secretions are two ways to promote airway clearance.
supplying humidified air and water to facilitate expectoration.
- Avoiding Complications: Keeping an eye out for symptoms of infection, such as fever, increased coughing, and sputum changes, that may indicate heightened vulnerability to chronic lung disease.
promoting proper placement and movement to avoid deep vein thrombosis and pressure injuries while preserving general functional status.
Psychological Support:
addressing patients' and family members' emotional discomfort associated with chronic disease through counselling, referrals to support groups, and reassurance.
Education of Patients and Families:
teaching patients how to manage their symptoms, take their medications as prescribed, stay away from triggers (like smoking), and know when to get help.
educating people about the value of routine medical checkups and monitoring for issues.
Advanced-stage end-of-life care:
supporting choices about palliative care alternatives, advanced care planning, and, as necessary, family counselling.
Notes
For more details visit 10.7812/TPP/14-186
