ST-segment elevation acute myocardial infarction following endoscopic hemostasis and blood transfusion for massive hemorrhage in a patient with gastric cancer

Introduction: To the best of our knowledge, few cases of acute myocardial infarction (AMI) associated with gastric hemorrhage and blood transfusion have been formally recorded in the medical literature and the clinical experience regarding such cases is limited.

Case presentation: An 83-year-old woman presented at the emergency department with hemorrhagic shock due to massive hematemesis and melena associated with severe anemia (hemoglobin of 6.7 g/dL) developed within last six hours. A normal 12-lead ECG trace was documented. Endoscopy revealed hemorrhagic gastric cancer and endoscopic clipping was performed along with plasma and red blood cells transfusion with hemodynamic stabilization. Afterwards, cardiologic examination was requested because of a newly developed shock. Repeat ECG revealed a 4 mm ST-elevation in inferior and V4r leads and atrial tachycardia with 3:1 AV block. Transthoracic echocardiography evidenced severe biventricular systolic dysfunction with inferior wall akinesia. Coronary angiography demonstrated acute thrombotic occlusion of the proximal right coronary artery (RCA), consistent with the diagnosis of inferior wall and right ventricular AMI. Volemic repletion and positive inotropic treatment was started because of cardiogenic shock. Percutaneous coronary intervention (PCI) with manual thrombus aspiration was performed extracting white thrombus, followed by plain old balloon angioplasty with acceptable angiographic result (TIMI III distal flow, intermediate severity residual stenosis, no dissection). At this point, ST elevation was remitted, hemodynamic stability was achieved, and antithrombotic treatment was avoided. Within one hour, hemodinamic instability and ST-elevation reoccurred, with the development of complete atrioventricular block. Repeat coronary angiography demonstrated acute thrombotic reocclusion of the RCA and PCI with drug eluting stent implantation was performed, along.

Particularity: We presented a case of ST elevation acute myocardial infarction treated by primary PCI appea-red in a neoplastic patient immediately after a massive gastric hemorrhage and severe anemia needing blood transfusion. Left ventricular systolic function improved to moderately depressed and complete resolution of ST elevation without pathological Q waves was documen-ted. Although the patient received antithrombotic therapy with enoxaparin and clopidogrel, no gastrointesti-nal bleeding was recorded presumably due to efficient endoscopic clipping of the bleeding source. However, three days after PCI, patient developed methicillin-resistant Staphylococcus Aureus pneumonia and died from septic shock within ten days from presentation with intravenous bolus administration of both unfrac-tionated heparin and eptifibatide. The patient received statin and antithrombotic therapy with enoxaparin and clopidogrel, but without aspirin.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)