title: Myocardial infarction, symptomatic third degree atrioventricular block and pulmonary embolism caused by thalidomide: a case report.
abstract: BACKGROUND
  Thalidomide has been reported to cause numerous thromboembolic events. Deep vein thrombosis and pulmonary embolism are more common. It can also cause bradycardia and even total atrioventricular block. Rarely, it causes coronary artery spasm and even myocardial infarction. But almost simultaneous onset of myocardial infarction, third degree atrioventricular block and pulmonary embolism in one patient has not been reported so far.
  
  
  METHODS
  A 53-year old man presented because of chest pain, nausea and then syncope for several minutes. Previous medical history included neurodermitis for which thalidomide was given and hypercholesterolemia with simvastatin taking. The patient didn't exhibit any other established risk factors for coronary artery disease. Electrocardiography showed sinus rhythm with third degree atrioventricular block and complete right bundle branch block, and precordial leads ST segment elevation. The diagnosis of acute coronary syndrome was suspected, but further coronary angiography demonstrated no flow-limiting lesions in coronary arteries, and temporary pacemaker was implanted. After admission, low SpO2 and elevated D-dimer level was mentioned. Further computed tomography pulmonary angiography revealed pulmonary embolism. Thalidomide was thought to be the cause of hypercoagulability and coronary spasm, so it was ceased immediately. Therapeutic low molecule weight heparin was initiated and then switched to warfarin with appropriate INR, and nifedipine was described for coronary spasm. The patient's symptoms completely relived and SpO2 recovered, and atrioventricular block had disappeared during hospitalization with pacemaker removed.
  
  
  CONCLUSIONS
  This is the very first case in which myocardial infarction, third degree atrioventricular block and pulmonary embolism almost simultaneously developed. We should be ware that anti-thrombotic prophylaxis, which needs further investigation for optimal drug and dosage, may be beneficial in thalidomide therapy. And it is also important to monitor patients taking thalidomide for signs and symptoms of bradycardia or higher degree atrioventricular block.
authors.affiliation: Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China. pumchzsy@126.com.
authors.forename: Shengyu
authors.initials: S
authors.lastname: Zhang
authors.affiliation: Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China. yj_pumch@126.com.
authors.forename: Jing
authors.initials: J
authors.lastname: Yang
authors.affiliation: Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
authors.forename: Xiaofeng
authors.initials: X
authors.lastname: Jin
authors.affiliation: Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China. shuyangzhang103@126.com.
authors.forename: Shuyang
authors.initials: S
authors.lastname: Zhang
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use; D054537:Atrioventricular Block / Q000139:chemically induced* / Q000175:diagnosis / Q000628:therapy; D002304:Cardiac Pacing, Artificial; D017023:Coronary Angiography; D003879:Dermatologic Agents / Q000009:adverse effects*; D004562:Electrocardiography; D006801:Humans; D019934:International Normalized Ratio; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000139:chemically induced* / Q000175:diagnosis / Q000188:drug therapy; D009450:Neurodermatitis / Q000175:diagnosis / Q000188:drug therapy*; D011655:Pulmonary Embolism / Q000139:chemically induced* / Q000175:diagnosis / Q000188:drug therapy; D012720:Severity of Illness Index; D013792:Thalidomide / Q000009:adverse effects*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014665:Vasodilator Agents / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D003879:Dermatologic Agents; D014665:Vasodilator Agents; D013792:Thalidomide