Transmural myocardial ischemia leads to a myocardial injury or necrosis in the event of ST-elevation myocardial infarction (STEMI). This review presents the case of ST-elevation myocardial infarction along with intracranial hemorrhage (ICH), which contraindicated the use of antiplatelet and antithrombotic therapies.
A 54-year-old female presented with dysarthria and left-sided weakness of unknown duration.
Tobacco use, hypertension
An acute right middle cerebral artery distribution ischemic infarct was revealed on a CT scan of the head. A thrombectomy was successfully performed.
The patient complained of nausea and chest discomfort post the procedure.
The following observations were made in an echocardiogram, electrocardiogram, and emergent CT of the head, respectively:
Hypokinesia of the entire apex
Acute anterior STEMI
Hemorrhagic conversion in the basal ganglia
A polymorphic ventricular tachycardia developed, which was managed by:
Cardiopulmonary resuscitation (CPR) and electrical cardioversion
Amiodarone therapy was started after accomplishing the return of spontaneous circulation.
Right coronary angiography revealed:
80% stenosis in the large obtuse marginal branch
Thrombotic occlusion of the mid-left anterior descending (LAD) artery
Chronic total occlusion of the right coronary artery
A 2.0 x 15 mm compliant balloon was used to perform percutaneous coronary intervention (PCI) with plain old balloon angioplasty (POBA). In addition, 81 mg aspirin daily was initiated in the patient two days later.
TIMI III flow in the LAD with residual stenosis was displayed on an elective coronary angiogram.
PCI of the LAD and obtuse marginal with two drug-eluting stents was performed successfully.
Left ventricle ejection fraction showed improvement.
According to the 2017 European Society of Cardiology guidelines for patients presenting with STEMI and undergoing PCI, antiplatelet and antithrombotic therapies are considered class I indications. Thrombus formation often occurs on the use of intracoronary foreign bodies. Hence, to prevent intra- and post-procedural thrombosis, antiplatelet and antithrombotic therapies are used. PCI is completely contraindicated in conditions that contraindicate the use of these therapies.
Acute ICH accompanied by STEMI is extremely challenging to manage. ICH contraindicates the use of antiplatelet and antithrombotic agents, whereas PCI requires their use. In this case, the patient had developed cardiac arrest, ICH, and occluded LAD. To restore flow to the occluded LAD, she underwent PCI with rapid POBA without the administration of antiplatelet or antithrombotic agents.