Anterior ST-Segment Elevation Myocardial Infarction Followed by Acute Popliteal Artery Occlusion in a 25-Year-Old Tobacco Smoker with Cannabis Use.
Yalçın Dalgıç, Denizhan Karaçimen, Ahmet Berk Duman et al.
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Case in brief
A 25-year-old man who smoked tobacco and occasionally used cannabis presented with an anterior ST-elevation myocardial infarction and underwent primary PCI of the left anterior descending artery. His ejection fraction was 30%, with severe apical wall-motion abnormality. Twelve days after discharge, acute left popliteal artery occlusion improved during therapeutic anticoagulation and was managed without revascularization. Testing showed elevated homocysteine with low vitamin B12 and folate; MTHFR C677T/A1298C compound heterozygosity was considered an accompanying finding, not a causal thrombophilia. A missed or transient apical thrombus was considered a plausible source of the limb event. He had no recurrent thrombotic or bleeding events during 18 months on individualized warfarin.
What made this case unusual
The second arterial event occurred in a separate vascular bed shortly after myocardial infarction in a young adult; a missed or transient left ventricular apical thrombus was considered a plausible, possibly most likely, explanation for the popliteal occlusion.
Diagnostic / clinical pearl
In a young patient with myocardial infarction followed by acute limb ischemia, consider a cardiac embolic source, particularly when severe apical wall-motion abnormality is present; do not assume an MTHFR variant establishes causal thrombophilia.