Beyond atherosclerosis: polycythemia vera presenting as ST-elevation myocardial infarction—a case report

Polycythaemia vera (PV) is a myeloproliferative neoplasm characterized by erythrocytosis, hyperviscosity, and increased thrombotic risk. Although arterial thrombosis is well recognized, acute myocardial infarction as the initial manifestation is uncommon and may be overlooked, particularly in patients without traditional cardiovascular risk factors. Early diagnosis is important, as management differs from standard ST-elevation myocardial infarction (STEMI) care and requires disease-directed therapy.

A previously healthy middle-aged woman presented with acute chest pain and electrocardiographic features of anterior STEMI. Emergency coronary angiography demonstrated a large thrombotic occlusion of the proximal left anterior descending artery without significant underlying atherosclerotic disease. Primary percutaneous coronary intervention with drug-eluting stent implantation restored TIMI III flow. Subsequent laboratory evaluation revealed marked erythrocytosis with a haemoglobin level of 20.2 g/dL and a haematocrit of 64%, prompting evaluation for a myeloproliferative disorder. Molecular testing confirmed JAK2 V617F-positive PV. Secondary prevention included dual antiplatelet therapy, therapeutic phlebotomy, and cytoreductive therapy with hydroxyurea. The patient had an uneventful recovery and remained clinically stable at the 6-month follow-up.

PV is an uncommon cause of acute myocardial infarction, typically presenting with extensive intracoronary thrombus despite minimal underlying atherosclerosis. Reported cases, including the present one, show a recurring pattern of STEMI in relatively young patients without conventional cardiovascular risk factors. Long-term outcomes depend on integration of standard acute coronary syndrome therapy with disease-specific cytoreductive strategies to reduce recurrent thrombosis. This case reinforces that acute coronary syndromes should not be routinely attributed to atherosclerotic disease when clinical and angiographic features are disproportionate to traditional risk profiles.