An 82-year-old man with a history of coronary artery bypass surgery, hypertension and small bowel gastrointestinal stromal tumour underwent cardiac risk evaluation prior to surgical resection of his tumour. He was asymptomatic from a cardiovascular perspective, but his activity level was less than four metabolic equivalents. Physical examination was notable for a 2/6 systolic murmur at the apex. ECG showed sinus rhythm. A transthoracic echocardiogram was performed (figure 1 and online supplementary video 1).DC1SP110.1136/heartjnl-2018-313413.supp1Supplementary file 1 heartjnl;heartjnl-2018-313413v1/F1F1F1Figure 1Transthoracic echocardiography. (A) Mitral valve continuous wave Doppler and (B) tricuspid valve continuous wave Doppler.

Acute coronary syndrome (ACS) is a term used to describe a spectrum of diseases associated with sudden reduced blood flow to the heart. Coronary artery thromboembolism is recognized as an important nonatherosclerotic cause of acute myocardial infarctions in 2.9% of ACS cases, with a long-term outcome indicating that coronary embolism patients represent a high-risk subpopulation. There are various risk factors for developing a coronary thromboembolism, with atrial fibrillation being the most frequently reported cause. Herein, we are presenting a case of a 65-year-old female patient who presented to the emergency department with sudden-onset pressure-like chest pain diagnosed as ACS due to nonatherosclerotic thromboembolism secondary to atrial flutter.

Esmolol (esmolol hydrochloride) is an intravenous cardioselective beta-1 adrenergic antagonist. Esmolol is FDA-approved for short-term duration use in control of supraventricular tachycardia, such as a rapid ventricular rate in patients with atrial fibrillation or atrial flutter. Esmolol is used in various settings including urgent care, perioperatively, and postoperatively. It is also indicated in sinus tachycardia, where a rapid rate requires intervention secondary to other comorbidities. Esmolol is further FDA-approved for tachycardia and hypertension induced by intubation. Off-label, it is used for rate and rhythm control in aortic dissection, acute coronary syndrome, non-ST elevation myocardial infarction, hypertensive emergencies, thyrotoxicosis, refractory ventricular tachycardia, refractory to defibrillation ventricular fibrillation, and to decrease catecholamine response during electroconvulsive therapy.