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A 71 year old man with a history of hypercholesterolaemia and smoking was admitted to the coronary care unit because of typical chest pain and dyspnoea at rest. One month before admission he underwent hip prosthesis replacement and had been treated with low molecular weight heparin (prophylactic dose), which was discontinued three days before the onset of symptoms. An ECG showed sinus tachycardia with right bundle branch block, ST segment depression, and deep negative T waves in leads V1–V5, suggesting severe anterolateral myocardial ischaemia (panel A). Troponin I was elevated. The patient, initially diagnosed as acute coronary syndrome, was treated with aspirin, low molecular weight heparin, and platelet glycoprotein IIb/IIIa inhibitors. Two hours later, emergency cardiac catheterisation was performed for haemodynamic instability (systolic arterial pressure of 70 mm Hg). Cardiac catheterisation showed normal coronary angiograms and pulmonary systolic pressure at the systemic level (panel B). Pulmonary angiography revealed complete thromboembolic occlusion by a large and mobile thrombus in the right pulmonary artery (panel C). The patient developed electromechanical dissociation and died during catheterisation.
This case illustrates the importance of clinical suspicion for the early diagnosis and treatment of pulmonary embolism.