A Middle-aged Woman With Recurrent Chest Pain With Troponin Elevation and Unobstructed Coronary Arteries | Acute Coronary Syndromes | JN Learning | AMA Ed Hub [Skip to Content]
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A Middle-aged Woman With Recurrent Chest Pain With Troponin Elevation and Unobstructed Coronary Arteries

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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.26

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Article Information

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 (m.khanji@qmul.ac.uk).

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.

References
1.
Pristipino  C , Sievert  H , D’Ascenzo  F ,  et al; Evidence Synthesis Team; Eapci Scientific Documents and Initiatives Committee; International Experts.  European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism.   Eur Heart J. 2019;40(38):3182-3195.PubMedGoogle ScholarCrossref
2.
Mas  J-L , Derumeaux  G , Guillon  B ,  et al; CLOSE Investigators.  Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke.   N Engl J Med. 2017;377(11):1011-1021. doi:10.1056/NEJMoa1705915PubMedGoogle ScholarCrossref
3.
Saver  JL , Carroll  JD , Thaler  DE ,  et al; RESPECT Investigators.  Long-term outcomes of patent foramen ovale closure or medical therapy after stroke.   N Engl J Med. 2017;377(11):1022-1032. doi:10.1056/NEJMoa1610057PubMedGoogle ScholarCrossref
4.
Lee  PH , Song  J-K , Kim  JS ,  et al.  Cryptogenic stroke and high-risk patent foramen ovale: the DEFENSE-PFO trial.   J Am Coll Cardiol. 2018;71(20):2335-2342. doi:10.1016/j.jacc.2018.02.046PubMedGoogle ScholarCrossref
5.
Mas  JL , Arquizan  C , Lamy  C ,  et al; Patent Foramen Ovale and Atrial Septal Aneurysm Study Group.  Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both.   N Engl J Med. 2001;345(24):1740-1746. doi:10.1056/NEJMoa011503PubMedGoogle ScholarCrossref
6.
Turc  G , Calvet  D , Guérin  P , Sroussi  M , Chatellier  G , Mas  J-L ; CLOSE Investigators.  Closure, anticoagulation, or antiplatelet therapy for cryptogenic stroke with patent foramen ovale: systematic review of randomized trials, sequential meta-analysis, and new insights from the CLOSE study.   J Am Heart Assoc. 2018;7(12):e008356. doi:10.1161/JAHA.117.008356PubMedGoogle Scholar
7.
Dao  CN , Tobis  JM .  PFO and paradoxical embolism producing events other than stroke.   Catheter Cardiovasc Interv. 2011;77(6):903-909. doi:10.1002/ccd.22884PubMedGoogle ScholarCrossref
8.
Pristipino  C , Anzola  GP , Ballerini  L ,  et al; Italian Society of Invasive Cardiology (SICI-GISE); Italian Stroke Association (ISA-AIS); Italian Association of Hospital Neurologists, Neuroradiologists, Neurosurgeons (SNO); Congenital Heart Disease Study Group of Italian Society Of Cardiology; Italian Association Of Hospital Cardiologists (ANMCO); Italian Society Of Pediatric Cardiology (SICP); Italian Society of Cardiovascular Echography (SIEC); Italian Society of Hemostasis and Thrombosis (SISET).  Management of patients with patent foramen ovale and cryptogenic stroke: a collaborative, multidisciplinary, position paper.   Catheter Cardiovasc Interv. 2013;82(1):E38-E51. doi:10.1002/ccd.24637PubMedGoogle ScholarCrossref
9.
Collado  FMS , Poulin  M-F , Murphy  JJ , Jneid  H , Kavinsky  CJ .  Patent foramen ovale closure for stroke prevention and other disorders.   J Am Heart Assoc. 2018;7(12):e007146. doi:10.1161/JAHA.117.007146PubMedGoogle Scholar
10.
Kuijpers  T , Spencer  FA , Siemieniuk  RAC ,  et al.  Patent foramen ovale closure, antiplatelet therapy or anticoagulation therapy alone for management of cryptogenic stroke? a clinical practice guideline.   BMJ. 2018;362:k2515. https://www.bmj.com/content/362/bmj.k2515. doi:10.1136/bmj.k2515PubMedGoogle ScholarCrossref
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