Introduction:
Coronary embolism (CE) is a significant yet underrecognized contributor to acute myocardial infarction (AMI), with prevalence estimates between 4% and 13% in angiographic and autopsy studies 1. Current literature indicates that intracoronary thrombus formation following plaque rupture due to atherosclerosis is the most common mechanism of myocardial infarction; however, non-atherosclerotic causes, such as CE, must also be considered 2,3. The management for CE differs from atherosclerotic causes, despite similar clinical presentations. In cases of CE, aspiration thrombectomy and balloon angioplasty are preferred, unlike AMI due to atherosclerosis, where coronary stenting is often indicated 4.
CE involves embolic material, such as thrombi, infectious elements, or neoplastic fragments, circulating to and obstructing the coronary arteries, leading to infarction of the myocardium supplied by the affected arteries. Multiple etiologies can give rise to CE, including paradoxical emboli from atrial septal defects, iatrogenic emboli from cardiothoracic procedures, and direct embolization from thrombi originating in the cardiac ventricles 5. To our knowledge, no cases of the latter have been reported in the literature, particularly in the context of cocaine abuse, highlighting the significance of this case report as a valuable contribution to to the literature.
Cocaine is recognized for its thrombogenic and angiospastic effects, promoting thromboembolism through several mechanisms6. Thrombi originating in the left ventricle or atrium are generally more likely to travel to the carotids or distal systemic circulation, given the linear course from the left ventricular outflow tract. However, coronary vessels are anatomically more protected from embolic events 7, making CE originating from a cardiac thrombus exceedingly rare, a factor that further underscores the uniqueness of our case.
Here, we present a rare case of a 42-year-old male who presented with chest pain following cocaine use. Investigations revealed an embolus obstructing the right coronary artery and a left ventricular apical thrombus on transthoracic echocardiography, which was proposed to be the embolic source, for which he underwent a successful aspiration thrombectomy.