Concomitant pulmonary embolism and myocardial infarction in the presence of underlying major thrombophilia, treated with low-dose systemic alteplase: A Case Report and review of the literature

Background: Pulmonary thromboembolism (PE) and Myocardial Infarction (MI) are lifethreatening conditions witch in rare case could be concomitant. Simultaneous onset is related to a single underlying disease, like paradoxical embolism or hypercoagulable state. Case summary: We report the case of a 78-year patient with recent surgery for prostate cancer, presented for acute onset of dyspnea and angina. Concomitant diagnosis of association of PE and inferior ST-Segment Elevation Myocardial Infarction (STEMI) was done by electrocardiography, troponin I change, Computed Tomography Pulmonary Angiogram (CTPA) and Coronary Angiography (CA). Filling defects were presents in both the main pulmonary artery and its branches and at origin of a bifurcation of marginal branch from coronary right artery. Intravenous tissue plasminogen activator (tPA)-alteplase was administered at a reduced dose (50 mg for 2 hours) due to high risk of bleeding. Clinical recovery was excellent. No Patent Foramen Ovale (PFO) was identified, but laboratory results revealed a combined thrombophilia with an abnormal protein C concentration and a heterozygous factor V Leiden mutation. Patient was discharged with Direct Oral Anticoagulants (DOAC) and is free of adverse events at 18 months follow-up. Conclusion: Early recognition of dual pathologies prompted in this case administration of thrombolytic therapy. Our observation showed that low dose tPA, may be a safe and effective treatment option for massive PE and STEMI, particularly in patients at a high risk of bleeding. Long term treatment with DOACs after Venous Thromboembolism (VTE) is a valuable therapeutic option in the presence of combined thrombophilia.