Unique Case of ST-Segment–Elevation Myocardial Infarction Related to Paradoxical Embolization and Simultaneous Pulmonary Embolization

Information about a real patient is presented in stages (boldface type) to an expert clinician (Dr Wąsek), who responds to the information, sharing his reasoning with the reader (regular type). A discussion by the authors follows. A 69-year-old man with no history of cardiac disease collapsed at home shortly after chest pain appearance. The ECG performed by paramedics during transportation and sent by the LifeNet system for evaluation to the Cardiology Center shows atrial fibrillation (AF) with a regular slow rhythm of 50 beats/min, suggesting complete heart block, ST-segment elevation in inferior and precordial V3 through V6 leads, ST-segment depression in aVL and in precordial V1 to V2 leads ( Figure 1A ). The clinical presentation and ECG allow for the diagnosis of ST-segment–elevation myocardial infarction (STEMI) and the patient receives aspirin 300 mg, clopidogrel 600 mg, unfractionated heparin 5000 IU, and morphine 5 mg IV on the way to the hospital. Within 3 hours after the onset of chest pain, the patient is presented to the emergency department of the nearest hospital with a 24/7 cardiac catheterization facility. Figure 1. A , Baseline ECG. Atrial fibrillation with a regular rhythm of 50 per minute (suggesting complete heart block), ST-segment elevation in inferior leads, and ST-segment depression in precordial leads. B , ECG on admission. The ECG shows slow AF, ST-segment elevation in inferior leads, ST-segment depression in I, aVL and in precordial V1-V3 leads; motion artifacts are also seen. AF indicates atrial fibrillation.Dr Wąsek: The clinical presentation and ECG are consistent with acute myocardial infarction (MI) with persistent ST-segment elevation. Networking with the mobile emergency unit, prehospital medical treatment, and invasive strategy implementation within the recommended timelines are in agreement with the current guidelines.1 Although prasugrel or ticagrelor should preferably be used, in this particular case, clopidogrel seems to be a …