Cancer: A Heart-Breaking Diagnosis

A 34-year-old previously healthy Hispanic woman presented to the emergency department with worsening left hip pain. Review of systems was significant for 15-pound weight loss, soaking night sweats, chills, and intermittent fevers over the past 3 months. On initial examination, she was hemodynamically stable and without focal clinical findings, with the exception of decreased breath sounds at the right base. Chest radiograph was significant for a large right lower lobe air space opacity (Figure 1). Computed tomography (CT) confirmed a cavitary lung mass; additional findings included a left ventricular (LV) filling defect consistent with an LV apical mass or thrombus (Figure 2), low density liver lesions, mediastinal lymphadenopathy, and a lytic left hip lesion highly concerning for metastatic neoplasm. Bronchoscopy and subcarinal lymph node biopsy demonstrated adenocarcinoma, which was presumed from a primary lung source. Transthoracic echocardiogram (TTE) (Figure 3) noted a spherical mass in the LV that appeared well-adherent to the apical aspect of the anterolateral wall in addition to an independently mobile echodensity adherent to this mass, which likely represented thrombus.

Figure 1: Chest Radiograph With Right Lower Lobe Airspace Opacity

Figure 1

Figure 2: CT Chest With Cavitary Right Lower Lobe Lesion and LV Filling Defect

Figure 2

Figure 3: TTE With LV Mass With Adherent Mobile Echodensity

Figure 3
Mass appears to be at the apex but view is notably foreshortened.

During a subsequent bone scan, she developed acute onset chest pain. Electrocardiogram (ECG) (Figure 4) demonstrated ST-segment elevations in leads II, III, and aVF consistent with ST-segment elevation myocardial infarction (STEMI). She was immediately taken to the cardiac catheterization laboratory where an acute occlusion was noted in the right coronary artery (RCA) (Figure 5) in the right posterolateral branch, right posterior descending artery, and the right marginal branch.

Figure 4: STEMI ECG

Figure 4A
Comparison Initial ECG on Presentation
Figure 4B

Figure 5: Coronary Angiography Preintervention

Figure 5

Based on the above coronary catheterization and clinical presentation, what is the likely etiology for the STEMI?

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