Non–ST-Segment Elevation Myocardial Infarction as the Initial Presentation of Chronic Lymphocytic Leukemia

BACKGROUND: Acute coronary syndrome is an uncommon initial manifestation of chronic lymphocytic leukemia (CLL). CASE SUMMARY: A 55-year-old man presenting with non-ST-segment elevation myocardial infarction. Coronary angiography revealed thrombotic total mid-left anterior descending artery occlusion, and intravascular ultrasound confirmed a fibro-fatty plaque, successfully treated with percutaneous coronary intervention. Laboratory testing revealed marked lymphocytosis, and flow cytometry confirmed Rai stage I CLL, managed conservatively under hematologic supervision. DISCUSSION: Myocardial infarction as the first manifestation of CLL is exceedingly rare and may occur due to leukostasis, coronary infiltration, or a paraneoplastic prothrombotic mechanism. The multimodality imaging assists in identifying mechanisms. TAKE-HOME MESSAGES: Persistent lymphocytosis during acute coronary syndrome warrants hematologic evaluation. CLL may rarely present with myocardial infarction. Recognition of this presentation is crucial for timely multidisciplinary management.