THE GREAT MASQUERADER: PULMONARY EMBOLISM PRESENTING AS ACUTE CORONARY SYNDROME

Background Acute pulmonary embolism (PE) remains one of the most challenging cardiovascular emergencies to diagnose because of its diverse and often deceptive clinical presentation. It may mimic acute coronary syndrome (ACS), bronchial asthma, pneumonia, or heart failure, resulting in delayed diagnosis and increased mortality. The coexistence of a right atrial thrombus (RAT), often described as a "clot-in-transit," is uncommon but is associated with a significantly worse prognosis

Methodology We report a diagnostically challenging case of a 48-year-old woman with newly diagnosed diabetes who presented with progressive dyspnea, chest tightness, and elevated troponin. ECG suggested NSTEMI, but echocardiography revealed a large mobile right atrial thrombus, right ventricular dysfunction, and severe pulmonary hypertension. CT pulmonary angiography confirmed multifocal PE and lower-limb deep-vein thrombosis. Systemic thrombolysis with alteplase, followed by anticoagulation, resulted in complete thrombus resolution and full clinical recovery.

Results Echocardiography demonstrated a large mobile right atrial thrombus, right ventricular dysfunction, and severe pulmonary hypertension. CT pulmonary angiography confirmed multifocal pulmonary emboli, while Doppler ultrasonography revealed deep-vein thrombosis. The patient received systemic thrombolysis with alteplase followed by anticoagulation with Rivaroxaban, resulting in complete thrombus resolution, marked clinical improvement, and full recovery.

Conclusions This case underscores the value of maintaining a high index of suspicion for PE, the pivotal role of bedside echocardiography in detecting clot-in-transit, and the benefit of prompt reperfusion therapy in achieving favorable outcomes