Intracoronary fibrinolysis as a bailout strategy for massive thrombotic catastrophe

CASE PRESENTATION This is the case of a 57-year-old man-Canadian immigrant-who presented to the emergency department due to chest pain. His past medical history showed hypertension, previous smoking, rheumatoid arthritis, and ischemic heart disease. He had previously undergone percutaneous angioplasty in 2006 in Canada. He had no past family history of heart condition or sudden cardiac death. His usual medication included aspirin, clopidogrel, ramipril, metoprolol, leflunomide, and prednisolone. He complained of constrictive chest pain of 2-hour evolution associated with dizziness. He denied syncope. He was admitted while clinically stable, and pain-free. Physical examination was normal. We performed serial electrocardiograms that appeared normal. Blood work showed elevated troponin I levels (5.23 ng/mL, normal range < 0.05 ng/mL). The remaining blood study was normal. Transthoracic echocardiogram showed good biventricular systolic function with inferior wall hypokinesis. The most likely diagnosis was acute coronary syndrome without ST-segment elevation (typical chest pain accompanied by elevated troponin I levels, and segmental hypokinesis). Other diagnoses like Takotsubo syndrome and myocarditis were less likely. Due to suspected acute coronary syndrome, he started anticoagulation with weight-adjusted enoxaparin (1 mg/Kg) and loading doses of ticagrelor (180 mg). About 24 hours later, the coronary angiography performed revealed the presence of right dominance (figure...