Conservative Acute Management of a Large Paradoxical Coronary Embolism

BACKGROUND: Coronary embolism is a rare cause of myocardial infarction (MI), often underdiagnosed and lacking standardized treatment guidelines. CASE SUMMARY: A 29-year-old woman with a history of pulmonary embolism presented with acute chest pain and elevated troponins. Coronary angiography revealed a large thrombus in the proximal left anterior descending artery without atherosclerotic disease. Investigations identified a patent foramen ovale (PFO) with bidirectional shunting and thrombophilia. The patient was managed conservatively with anticoagulation and dual antiplatelet therapy, resulting in complete thrombus resolution. PFO closure was performed 6 months later. DISCUSSION: Coronary embolism accounts for approximately 9% of MI cases in young adults, with PFO and hypercoagulable states being predisposing factors. Our case demonstrates the efficacy of conservative medical management as a viable initial strategy in hemodynamically stable, asymptomatic young patients with non-flow-limiting coronary embolus with large thrombus burden. TAKE-HOME MESSAGES: Paradoxical coronary embolism should be considered in young patients presenting with MI. Conservative management with antithrombotic therapy may be an effective acute therapeutic strategy.