Myocardial Infarction With PFO: Distinguishing SCAD From Coronary Embolism.

BACKGROUND

Myocardial infarction in young patients without traditional cardiovascular risk factors raises concern for nonatherosclerotic etiologies such as spontaneous coronary artery dissection and coronary embolism.

CASE SUMMARY: A 38-year-old woman with no past medical history presented with acute substernal chest pain associated with nausea and vomiting. Evaluation was consistent with non-ST-segment elevation myocardial infarction (NSTEMI), with dynamic elevation in high-sensitivity troponin levels and ischemic electrocardiographic changes. Transthoracic echocardiography demonstrated mildly reduced left ventricular systolic function with regional wall motion abnormalities not confined to a single coronary distribution as well as a large right-to-left interatrial shunt with atrial septal aneurysm. Coronary angiography identified focal occlusion of a septal perforator branch of the left anterior descending artery. She was managed with guideline-directed NSTEMI therapy and later underwent outpatient patent foramen ovale closure.

DISCUSSION: This case illustrates the diagnostic complexity of NSTEMI in young patients when angiographic findings and cardiac imaging suggesting nonatherosclerotic etiologies.

TAKE-HOME MESSAGE: NSTEMI in young patients warrants standard acute coronary syndrome management while concurrently evaluating for alternative mechanisms of myocardial injury.