Myocardial Infarction in a Patient With Homozygous Plasminogen Activator Inhibitor-1 (PAI-1) 4G/4G Mutation: A Case Report

Non-ST-elevation acute coronary syndrome (NSTE-ACS) resulting from genetic thrombophilias such as plasminogen activator inhibitor-1 (PAI-1) polymorphisms is extremely uncommon. We report the case of a 47-year-old male with no significant past medical history, aside from marijuana use, who presented with chest pain and elevated troponin levels. Coronary angiography demonstrated a thrombotic 100% occlusion of the left circumflex artery. A hypercoagulability workup revealed a homozygous 4G/4G PAI-1 gene polymorphism, consistent with an increased thrombotic predisposition, with marijuana use serving as a possible trigger. The patient was treated with aspirin, clopidogrel, and apixaban. This case illustrates a rare association between myocardial infarction and the PAI-1 4G/4G polymorphism and underscores the importance of considering thrombophilia testing in young patients with ACS who lack conventional cardiovascular risk factors.