Sudden death from acute thromboembolic occlusion of the left coronary ostium

The patient was a 55-year-old woman who experienced anterior chest pain after drinking a cup of coffee. The patient had no risk factor for cardiac disease other than mild non- insulin-dependent diabetes mellitus. The patient did have a history of asthma and was on a steroid taper, taking 20 mg of prednisone daily. The patient's physical examination results were within normal limits. Her laboratory data were normal, except for a glucose level of 499 mg/dl and a urinalysis revealing more than 4+ glucose with large ketones. Venous blood gas pH was 7.36, and troponin I, creatinine kinase-MB, electrocardiogram, and chest film were normal. The patient was admitted to rule out acute coronary syndrome. During the placement into an inpatient bed, the patient sustained a cardiac arrest with a narrow complex ventricular rhythm without pulse, from which she could not be resuscitated. The postmortem examination of the lungs revealed no evidence of thromboemboli. The coronary arteries revealed mild atherosclerosis. Examination of the aortic root revealed complete occlusion of the left coronary ostium by a large premortem nonorganized fresh thromboembolus, which was easily removed by passing a probe retrograde from the left main coronary artery (Fig. 1). Microscopically, there were also small thromboemboli in both the distal right and left coronary intramyocardial vessels. An extensive search of the heart and all major vessels was undertaken to identify the source of the possible thromboemboli, and none could be identified. A Medline search of the literature revealed no other similar case.