Herein, we present the case of a 31-year-old patient who had chest pain after a cesarean-section at 36 weeks of amenorrhea. As past medical history, this patient has a homozygous sickle cell disease. The patient complained of pressure in the chest 2 h after cesarean-section, radiating to the shoulders and the back. Blood pressure was 150/100 mm Hg (symmetrical on both arms) and heart rate was 98 bpm. Per-critical ECG showed an ST-segment elevation in aVR, V1–V2 with a mirror in other leads (Fig. 1). A few minutes later, the pain had disappeared and the ECG changed. Cardiac echography found a 50% left ventricular ejection fraction with homogeneous hypokinesia. There was no argument for acute pulmonary heart disease or a patent foramen ovale after contrast test. Investigations showed hemoglobin at 6 g/dl and an increase in troponin by 9ui (N<0.04ui). Cardiac-CT was performed in emergency, which showed no coronary abnormality but showed bilateral pulmonary embolism (PE) (Fig. 2).
Figure 1.
ECG at initial management
Figure 2.
Cardiac-CT
Atypical presentations are common for PE. However, the presentation with chest pain and ST-segment elevation on ECG is exceptional. Two pathophysiological hypotheses have been proposed: (1) a right ventricular ischemic strain due to right ventricular dysfunction associated with low coronary output arising from a low cardiac output and (2) a paradoxical coronary embolism because of patent foramen ovale reopening due to elevated pressure in right heart cavities.