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A middle-aged woman presented with chest pain, elevated troponin-T of 1037 ng/L (normal <14 ng/L; to convert to micrograms per liter, multiply by 1), and anterior T-wave inversion on electrocardiography. She was a smoker with hypertension and kidney dysfunction, with a history of left-sided paresthesia.
Coronary angiography demonstrated unobstructed coronary arteries. Cardiovascular magnetic resonance (CMR) imaging revealed subendocardial midinferolateral late gadolinium enhancement with corresponding hypokinesis consistent with a partial-thickness myocardial infarction. Prolonged Holter monitoring showed no evidence of atrial fibrillation.
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Paradoxical embolism through PFO causing recurrent systemic embolism
D. Closure of PFO and antiplatelet therapy
A PFO is present in about 25% of the population and may coexist without etiologic implications in a patient with unexplained systemic embolism.1 Owing to the complexity of variables involved and the lack of rigorous scientific evidence, no position can be made regarding quantitative assessment of the role of a PFO. Therefore, this should be evaluated with critical clinical judgment in an multidisciplinary setting, weighing up the following features on an individual basis: patient characteristics, imaging stroke/infarction pattern, PFO characteristics, and case-specific clinical clues.1 An atrial septal aneurysm and/or a moderate to severe shunt are strongly associated with a causal role of PFO in patients with cryptogenic stroke in observational and randomized studies.2- 6
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Corresponding Author: Mohammed Y. Khanji, MBBCh(Hons), PhD Newham University Hospital and Barts Heart Centre, Barts Health NHS Trust, Glen Road, London E13 8SL, England (email@example.com).
Published Online: March 10, 2021. doi:10.1001/jamacardio.2021.0116
Conflict of Interest Disclosures: None reported.
Additional Contributions: We acknowledge Fizzah Choudhry, MBBS, BSC, MRCP, PhD, of Barts Heart Centre, London, England, who was involved in the patient’s treatment. No compensation was received from a funding source for these contributions.
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