Investigations and treatment:
A twelve- lead ECG showed 1mm ST elevations in inferior leads with no
reciprocal changes and a sinus rhythm at a rate of 60 beats/minute(Fig 1) . A STEMI code was called, and the patient was taken
emergently to the Cath Lab. She was started on acute coronary syndrome
(ACS) treatment including oral aspirin 324 milligrams, oral clopidogrel
600 milligrams, and intravenous heparin 5000U. Significant laboratory
data showed a troponin of 0.615NG/ml, hemoglobin of 8.7g/dL and white
blood cell count of 13.7 x 109/L.
Coronary angiogram revealed a saddle clot (thrombus) involving the
distal left main artery, left circumflex, and proximal LAD (Fig
2). TIMI flow grade was 3 throughout and no intervention was taken
place during coronary angiogram. There was also an occlusion in the
apical portion of the LAD. Right coronary artery did not have any
abnormalities. Echocardiogram revealed an estimated ejection fraction of
55-60% with apical septal dyskinesis and a normal diastolic function.
There was no evidence of an intra-atrial shunt or left atrial appendage.
Patient was admitted to the cardiac care unit (CCU) and was started on
intravenous tirofiban for 10 hours, oral aspirin 81 milligrams daily,
oral clopidogrel 75milligrams daily, and intravenous heparin drip as per
ACS protocol. Troponin peaked at 11 NG/ml. Patient was given 2 units of
PRBC due to persistent vaginal bleeding. Doppler of the lower
extremities did not reveal any evidence of a DVT. Telemetry over 48
hours in hospital stay did not show any evidence of cardiac arrhythmia.
Thrombophilia testing lab results showed antithrombin activity of 88%,
antithrombin III AG 79%, cardiolipin AB IGA <9.4APL, beta-2
glycoprotein IGG <9.4 U/ml, beta-2 glycoprotein IGM
<9.4 U/ml, Cardiolipin AB IGM MCLIP <9.4 MPL,
Cardiolipin AB IGG GCLIP <9.4 GPL, Prothrombin G20210A Gene
negative, beta-2 glycoprotein AB IGA <9.4 U/ml, PSPT IGG
<9.4 U, PS/PT IGM 20.0 U and platelet count of 376 K/UL.