Cocaine-Provoked Pulmonary Vein Thrombosis

BACKGROUND: Coronary artery embolism (CAE) is an underrecognized cause of myocardial infarction, particularly in patients with limited coronary atherosclerosis. Pulmonary vein thrombosis (PVT) as an embolic source of CAE has rarely been described. CASE SUMMARY: A middle-aged female with known active cocaine use and Factor V Leiden mutation presented following out-of-hospital ventricular fibrillation cardiac arrest. Coronary angiography revealed thrombotic left circumflex artery occlusion without atherosclerosis. Computed tomography identified a nonocclusive left superior pulmonary vein thrombus as a possible embolic source. Drug-eluting stent implantation and apixaban were initiated; ticagrelor was de-escalated to clopidogrel given anticoagulation. Thrombus resolved at 12 weeks. DISCUSSION: Cocaine-provoked PVT causing CAE in inherited thrombophilia is a rare mechanism requiring embolic source evaluation and tailored management. TAKE-HOME MESSAGES: In patients with cryptogenic CAE, cocaine use with inherited thrombophilia should prompt PVT evaluation. When post-percutaneous coronary intervention antiplatelet therapy requires anticoagulation, P2Y12 de-escalation to clopidogrel reduces bleeding risk.