Quiz

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

JAMA Cardiology

May 1, 2021

JAMA Cardiology Clinical Challenge

Article Information and Disclosures

Jun Hua Chong, MBBS^1,2;

Andreas Baumbach, MD^3,4,5,6;

Mohammed Y. Khanji, MBBCh(Hons), PhD^3,4,7

Author Affiliations

¹Cardiologist at the National Heart Centre Singapore, Singapore
²Duke-National University of Singapore Medical School, Singapore
³Queen Mary University of London, London, England
⁴Barts Heart Centre, London, England
⁵Yale School of Medicine, New Haven, Connecticut
⁶European Association of Percutaneous Cardiovascular Interventions, Sophia Antipolis, France
⁷Newham University Hospital, Barts Health National Health Services Trust, London, England

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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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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

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.PubMed Google Scholar Crossref

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/NEJMoa1705915 PubMed Google Scholar Crossref

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/NEJMoa1610057 PubMed Google Scholar Crossref

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.2018.02.046 PubMed Google Scholar Crossref

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/NEJMoa011503 PubMed Google Scholar Crossref

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.117.008356 PubMed Google Scholar

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.22884 PubMed Google Scholar Crossref

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.24637 PubMed Google Scholar Crossref

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.117.007146 PubMed Google Scholar

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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.k2515 PubMed Google Scholar Crossref

A Middle-aged Woman With Recurrent Chest Pain With Troponin Elevation and Unobstructed Coronary Arteries

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Management of Patients With a Patent Foramen Ovale With History of Stroke or TIA

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A Middle-aged Woman With Recurrent Chest Pain With Troponin Elevation and Unobstructed Coronary Arteries

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Management of Patients With a Patent Foramen Ovale With History of Stroke or TIA

A Middle-Aged Woman With Non–ST-Elevation Myocardial Infarction and Unobstructed Coronary Arteries

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