Early ST-segment elevation acute myocardial infarction after thrombolytic therapy for acute ischemic stroke

Abstract

Rationale:Acute ST-segment elevation myocardial infarction (STEMI) is a rare complication of acute ischemic stroke (AIS) during thrombolytic therapy. We report a case of STEMI occurring 40 minutes after thrombolytic therapy for AIS and discuss the possible mechanisms and therapeutic approaches.Patient concerns:A 87-year-old woman with a history of arterial hypertension was admitted for acute onset of right-sided limb weakness 2 hours before arrival at the emergency department. Forty minutes after intravenous recombinant tissue plasminogen activator (i.v. rtPA) administration for AIS, STEMI occurred (signaled by a third-degree atrioventricular block).Diagnoses:The diagnoses were AIS and STEMI. Coronary angiography confirmed right coronary artery occlusion.Interventions:Four hours after the onset of STEMI, stenting was performed, normalizing the coronary blood flow.Outcomes:The patient died 2 days thereafter because of persistent cardiogenic shock.Lessons:Our case is remarkable owing to the unusually early (<1 hour) occurrence of STEMI after i.v. rtPA administration. A third-degree atrioventricular block after thrombolysis for AIS could signal a STEMI onset. New and ongoing trials are assessing whether adjunct administration of direct thrombin inhibitors of rtPA in the first 24 hours after thrombolysis for AIS can prevent early recurrent ischemic events.

Coronary aspiration thrombectomy after using intravenous recombinant tissue plasminogen activator in a patient with acute ischemic stroke: a case report

“…However, the complication of vessel occlusion is uncommon in this situation, especially myocardial infarction, which has only been described in some published cases. [3][4][5] There is still controversy regarding the strategy of treatment for rt-PA use. Our patient had contraindications to anticoagulants and antiplatelets for up to 24 hours.…”

“…During follow-up post-treatment, no reocclusion of the coronary artery and no cerebral hemorrhage were observed. Manea et al 4 also directly performed aspiration in a patient with myocardial infarction after thrombolytic therapy, but this resulted in vessel re-occlusion after a few minutes. Therefore, they had to deploy a coronary stent in the acute stage.…”

Acute Ischemic Stroke Associated with Myocardial Infarction: Challenges and Management

“…The most common scenario is development of AIS after AMI, followed by concurrent presentation of both events, and rarely development of AMI after stroke. 3,5,6,10,40 The pathogenesis of cerebral and coronary occlusions is different. Acute cerebral occlusions are more heterogeneous in nature, including from embolic thrombi from cardiac and arterial origins in addition to in situ atherosclerosis with overlying thrombosis, whereas ACS from coronary occlusion is more often from atherosclerotic plague with thrombosis.…”

“…48,49 In rare cases, intravenous thrombolytic therapy for AIS may induce development of STEMI by either fragmentation of a preexisting intracardiac thrombus or lysis of fibrin clot within the necrotic myocardial wall if patient has a persistent or unsuspected subacute MI. 40,50 Currently, many randomized clinical trials considered the duration of heightened ischemic stroke risk after AMI as 1 month. 7,51 However, significantly elevated risk of ischemic stroke has been identified beyond the 1-month time window in both STEMI and non-STEMI patients without a history of atrial fibrillation.…”

Paradoxical Myocardial Infarction After Thrombolytic Therapy for Acute Ischemic Stroke

“…Myocardial infarction (MI) after tPA use is a rare complication with unknown incidence and rarely reported [ 2 ]. Our case represents the appropriate use of tPA for acute ischemic stroke per the inclusion criteria which is well documented in the literature, however, with an unexpected development of acute MI immediately following tPA administration.…”