Recurrent myocardial infarctions in a young football player secondary to thrombophilia, associated with elevated factor VIII activity

Abstract

Myocardial infarction (MI) due to coronary atherosclerosis in young adults is uncommon; rare causes such as cocaine abuse, arterial dissection, and thromboembolism should be considered. A 21-year-old football player, and otherwise healthy African American man, developed chest pain during exercise while bench-pressing 400 lbs. Acute MI was diagnosed based on physical examination, electrocardiography findings, and elevated cardiac enzymes. Coronary arteriography showed a thrombus occluding the proximal left anterior descending artery (LAD). Aggressive antiplatelet therapy with aspirin, clopidogrel, and eptifibatide was pursued, in addition to standard post-MI care. This led to the successful resolution of symptoms and dissolution of the thrombus, demonstrated by repeat coronary arteriography. Five months later, he presented with similar symptoms during exercise after lifting heavy weights, and was found to have another acute MI. Coronary arteriography again showed a thrombus occluding the LAD. No evidence of coronary artery dissection or vasospasm was found. Only mild atherosclerotic plaque burden was observed on both occasions by intravascular ultrasound. A bare metal stent was placed at the site as it was thought this site had acted as a nidus for small plaque rupture and thrombus formation. Elevated serum factor VIII activity at 205% (reference range 60%–140%) was found, a rare cause of hypercoagulability. Further workup revealed a patent foramen ovale during a Valsalva maneuver by transesophageal echocardiography. Both events occurred during weight lifting, which can transiently increase right heart pressure in a similar way to the Valsalva maneuver. In light of all the findings, we concluded that an exercise-related increase in factor VIII activity led to coronary arterial thrombosis in the presence of a small ruptured plaque. Alternatively, venous clots may have traversed the patent foramen ovale and occluded the LAD. In addition to continuing aggressive risk factor modification, anticoagulation therapy with warfarin was initiated with close follow-up.

Acute myocardial infarction in a 41-year-old woman due to elevated factor VIII: a case report

“…Then comes a major discussion about anticoagulation against the hypercoagulability state. As part of the secondary prevention of the development of the thrombi formation, anticoagulants (warfarin and other vitamin K antagonists) showed their effectiveness in patients with myocardial infarction and other arterial thromboses such as atrial fibrillation and peripheral arterial disease [ 6 ] and here, we suggested that it may be valuable to screen for these thrombotic disorders to reduce recurrence [ 15 ] and severe complications such as catastrophic thrombotic syndrome (thrombotic storm) [ 16 ].…”

Progressively Worsening Premature Coronary Artery Disease: Adding Anticoagulation Stabilizes–Reverses Clinical Symptomatic Disease Progression in Thrombophilic–Atherothrombotic Patients: A Pilot Study

“…[32][33][34] Additionally, premature atherothrombosis has been linked to elevated factor VIII. 35 The clinical importance of thrombophilia in arterial thrombosis is emphasized by the superiority of oral anticoagulants versus aspirin alone in secondary prevention of acute arterial ischemia. 36,37 In carriers of hemophilia, a mild decrease in coagulability has a significant protective effect against fatal ischemic heart disease.…”

Myocardial Infarction in Young Athletes

“…In young athletes under 35-40 years old, the occurrence of MI type I, which is typically associated with atherosclerosis resulting from risk factors such as obesity, diabetes, smoking, or dyslipidemia, is only one of the mechanisms [9,10]. Many MIs are of the type II mechanism caused by oxygen supply-demand mismatch from abnormalities of the coronary arteries, spontaneous coronary artery dissection, coronary artery spasm, hypercoagulability, or consequences of anabolic steroids use.…”