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Non- St Elevation Myocardial Infarction Or A Missed Diagnosis Of Pulmonary Embolism: A Case Of Cardiac Arrest Secondary To Acute Pulmonary Embolism In A Woman Presenting With Typical Angina Pain

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A 52-year-old woman with past medical history of type 2 diabetes mellitus, hypertension and chronic obstructive pulmonary disease presented with complaints of central chest tightness/heaviness with radiation to the left shoulder. Electrocardiogram (ECG) showed T wave inversion in leads V1 and V2 and troponin level was raised at 0.2 micrograms/litre. A diagnosis of NSTEMI (non-ST elevated myocardial infarction) was made and she was started on appropriate treatment. The next day she had an in-patient coronary angiogram which showed no evidence of obstructive coronary artery disease and patient was thought to have coronary microvascular disease. Heparin drip was stopped and patient was continued on aspirin, statin and advised on strict glycemic control. She remained completely asymptomatic. However, the next day she coded. She was found down and unresponsive. CPR was initiated and return of spontaneous circulation was achieved after one round of compressions. She was neurologically intact post-arrest. Further workup revealed a new complete right bundle branch block and S1Q3T3 pattern on ECG. D-dimer was elevated at 6000 and lower extremity venous ultrasound showed chronic deep venous thromboses (DVT) in the left distal femoral and popliteal veins. Echocardiogram showed an ejection fraction of 45%, severely dilated left ventricle and systolic flattening of ventricular septum. On V/Q scan there was intermediate probability of PE however cardiac MRI showed filling defects consistent with thrombi in the right and left pulmonary arteries. Patient was continued on heparin and eventually transitioned to novel oral anticoagulant (NOAC).

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