Polycythemia Vera Presenting as ST-Segment Elevation Myocardial Infarction

      An 80-year-old woman with a history of hypertension, prediabetes, chronic kidney disease (stage 3b), and a remote ischemic stroke without residual deficits presented to the emergency department complaining of several hours of epigastric discomfort and malaise. An electrocardiogram (ECG) performed at triage revealed normal sinus rhythm with >1 mm ST elevation in leads V4-6 and lead 1, reciprocal ST depression in aVR, and Q waves in V1 and V2 (Fig. 1). The troponin I was elevated to 1.66 ng/mL (reference range <0.03). The patient was loaded with aspirin and ticagrelor and taken directly to the cardiac catheter lab. Left-sided heart catheterization revealed embolic-appearing occlusions of the distal apical left anterior descending (LAD) artery and a distal superior branch of D1, which were not amenable to percutaneous coronary intervention (Fig. 2). She was transferred to the medical telemetry unit for further monitoring.
      Figure 1
      Figure 1Admission electrocardiogram. Normal sinus rhythm with >1 mm ST elevation in leads V4-6 and lead 1, reciprocal ST depression in aVR, and Q waves in V1 and V2.
      Figure 2
      Figure 2Coronary angiography that demonstrates stump occluded D1 (black arrow) and embolic appearing occlusions of distal apical left anterior descending artery (white arrows).
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