Revista Mexicana de Cardiología C C B R Vol. 27 No. 4 October-December 2016 Acute myocardial infarction due to coronary embolism in atrial fibrillation: case presentation and systematic review Infarto agudo de miocardio debido a embolia coronaria en fibrilación auricular: presentación de caso y revisión sistemática Juan Carlos Díaz,* Danilo Weir,** William Uribe,*** Julián Aristizábal,**** Jorge Velásquez,**** Jorge Marin,**** Mauricio Duque***** Key words: Acute myocardial infarction, atrial ABSTRACT RESUMEN fi brillation, coagulation, coronary Atrial fi brillation is the most common sustained arrhyth- La fi brilación auricular es la arritmia sostenida más embolism. mia in the general population, responsible for signifi cant común en la población general, responsable de una gran morbidity and mortality due to an increased risk of morbilidad y mortalidad debido a un mayor riesgo de Palabras clave: systemic embolism. The anatomic and hemodynamic embolia sistémica. Las características hemodinámicas y Infarto agudo characteristics of the cardiovascular system direct most anatómicas del sistema cardiovascular conducen directa- de miocardio, emboli towards the central nervous system or the periph- mente la mayoría de los émbolos hacia el sistema nervioso fi brilación auricular, eral circulation, being coronary embolism an uncommon central o a la circulación periférica, siendo la embolia coagulación, embolia event. This has led to a paucity in the available medical coronaria infrecuente. Esto ha llevado a una escasez en coronaria. literature regarding the importance of atrial fi brillation as la literatura médica sobre la importancia de la fi brilación a cause of acute myocardial infarction and the treatment auricular como causa de infarto agudo de miocardio y * Cardiology and these patients should be off ered, with most of the evidence del tratamiento que debe ser ofrecido a estos pacientes, Electrophysiology. CES arising from case reports and small case series. A case con la mayoría de las pruebas derivadas de informes Cardiología. Clínica of acute myocardial infarction associated with coronary de casos y series de casos pequeñas. Un caso de infarto CES, Medellín. ** Medical Student. embolism in a patient with new onset atrial fi brillation agudo de miocardio asociado con embolia coronaria en Fundación Universitaria who was successfully treated with thrombus aspiration is un paciente con fi brilación auricular de nueva aparición San Martin, Sabaneta. presented, followed by a systematic review of the topic. que fue tratada exitosamente con tromboaspiración es pre- *** Cardiology and The objective of this review is to establish the clinical sentado, seguido de una revisión sistemática del tema. El Electophysiology, characteristics of patients with coronary embolism due to objetivo de esta revisión es determinar las características CES Cardiología. atrial fi brillation and determine the best treatment options clínicas de los pacientes con embolia coronaria debido a Electrophysiology chief based on the available evidence. fi brilación auricular y determinar las mejores opciones de CES Cardiología and tratamiento basadas en la evidencia disponible. Centros Especializados de San Vicente Fundación, Medellín and Rionegro. **** Cardiology and Electrophysiology, CES INTRODUCTION stroke, being responsible for about 1 of every Cardiología. www.medigraphic.org.mx5 ischemic strokes.1-4 Management is based ***** Cardiology and trial fibrillation (AF) is the most common on controlling underlying diseases which Electrophysiology, CES Cardiología. Cardiology Asustained arrhythmia worldwide, being can trigger or perpetuate the arrhythmia chief, CES Cardiología. the main reason for arrhythmia related hos- and defining if the patient is suitable for a pitalization; AF is also associated with a sig- rhythm vs rate control strategy; whichever Received: 1 01/06/2016 nificant increase in mortality. Furthermore, it the strategy chosen evaluation and treatment 1,2 Accepted: is an important cause of cerebral embolism, of embolic risk is warranted. Most emboli 04/11/2016 with five-fold increase in the risk of ischemic are directed towards the cerebral circula- Rev Mex Cardiol 2016; 27 (4): 171-180 www.medigraphic.com/revmexcardiol 172 Díaz JC et al. Acute myocardial infarction due to coronary embolism in atrial fi brillation tion, with less than 11% of embolic events CASE PRESENTATION directed towards systemic circulation.5 The incidence of acute myocardial infarction A 52-year-old man with history of arterial hy- (AMI) as a consequence of AF is unknown,6 pertension (CHA2DS2VASC: 1) was admitted with scarce information available in medi- in June 2015 for palpitations and nausea; his cal literature. Nevertheless, AMI caused by initial ECG in the emergency room reveal- coronary embolism in AF is known to be an ing atrial fibrillation. He described previous infrequent condition (considering the num- episodes of short lasting palpitations, without ber of patients with arrhythmia); a recently previous documentation of AF (first detected published study using the AVERROES, RELY, AF). After initial evaluation, he refered chest ACTIVE A & ACTIVE W database (including pain oppression without ECG changes sug- more than 37,000 patients with an average gesting acute ischemia (Figure 1) but because follow up of 2.4 years, equivalent to 91,746 of an elevated troponin I result (0,595 ng/mL; patient-years) found no episodes of AMI as- reference value: 0,012-0,024 ng/mL) he was sociated to AF-related embolism.5 This low diagnosed with an acute myocardial infarction incidence has led to underepresentation of without ST elevation (NSTEMI). Anticoagulant this association in medical literature; risk (enoxaparine 1 mg/kg each 12 hours) and factors, affected patient’s characteristics anti-platelet aggregation (load of acetylsalicylic and appropriate management are currently acid 300 mg and clopidogrel 300 mg both PO) unknown. A case of AF-related coronary em- were administered and the patient underwent bolism is presented, followed by a systematic coronary angiography. During the procedure, review of the available medical literature to a fresh thrombus in the proximal portion of the summarize the best evidence available. The anterior descendent artery (ADA) with total oc- primary objective is to identify the general clusion of distal circulation was found (Figure 2), characteristics of patients who suffer an AMI without significant atherosclerosis. Mechanical by coronary embolism associated with AF. thrombectomy with aspiration of a red throm- The secondary objective is to define the most bus was performed out, restoring blood flow appropriate treatment strategy for this group through the vessel with a residual oclussion at of patients. the distal portion of the ADA. Subsequent at- www.medigraphic.org.mx Figure 1. 12 lead ECG upon arrival at the emergency room. Atrial fi brillation (lack of a P wave, with variable RR interval) without acute ischemic changes. Rev Mex Cardiol 2016; 27 (4): 171-180 www.medigraphic.com/revmexcardiol Díaz JC et al. Acute myocardial infarction due to coronary embolism in atrial fi brillation 173 tempts during the same procedure completely boembolus» OR «coronary artery embolization») restored normal blood flow. AND atrial fibrillation; the search was limited to A transthoracic echocardiogram performed publications written in English and/or Spanish. after coronary angiography showed a normal Additionally, a search in SciELO and LILACS ejection fraction (60%) without any contractility was performed using the English terms and their disorders; a transesophageal echocardiogram Spanish translation («embolismo coronario» OR performed the next day excluded left atrial «embolismo de arteria coronaria» OR «trombo- trhombus and pharmacologic cardioversion embolia coronaria») AND fibrilación auricular. was undertaken using an intravenous amioda- Publications were included if coronary embo- rone infusion. The patient was discharged with lism related to AF was demonstrated by coro- anti-platelet therapy (acetylsalycilic acid 100 nary angiography; publications what included mg PO/24 h, clopidogrel 75 mg PO/24 h), oral patients with prosthetic valves or alternative anticoagulation with warfarin and anthiarrhyth- sources of emboli (ateromatosis with suspect mic treatment (propafenone 150 mg PO/12 of ateroemboli, infective endocarditis) were h and metoprolol succinate 50 mg PO/24h). excluded. Additionally, bibliographic references One month after the index event, pulmonary of the included publications were reviewed, vein ablation was performed to decrease the aiming to identify studies which had not been risk of arrhythmia recurrence. After a six month included during the initial search. The PubMed follow up, no new episodes of AF have been search yielded 32 results, out of which 19 were documented during Holter monitoring, and the initially excluded due to an alternative source of patient has had no angina episodes. embolism because they were unrelated with the study question (coronary embolism associated ATRIAL FIBRILLATION to AF without prosthetic valves or another em- RELATED CORONARY EMBOLISM: boli causes); another publication was excluded SYSTEMATIC REVIEW because it was a letter to editor. The EMBASE search yielded 53 results in total, out of which Methods: A systematic search of databases 30 were excluded due to an alternative source (Pubmed, EMBASE and Cochrane) was made of embolism; 7 were unrelated to the study in November 2015 using the terms («coronary question