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Acute stroke with concomitant acute myocardial infarction: will you thrombolyse?

Maciel R, Palma R, Sousa P, Ferreira F, Nzwalo H - J Stroke (2015)

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Centro Hospitalar do Algarve (CHA), Faro, Portugal. ; Stroke Unit, Centro Hospitalar do Algarve (CHA), Faro, Portugal.

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Dear Sir: Concomitant occurrence of acute myocardial infarction (MI) and stroke is infrequently encountered in emergent patients... IV t-PA (0.9 mg/kg over 1 hour, total dose 80 mg) was administered 2 h after stroke onset... The patient's condition improved with thrombolysis (NIHSS score, 4)... Results of the remaining investigations, including a metabolic panel (glucose levels, hemogram, blood coagulation times, ionogram, renal function, hepatic enzymes), were normal... The patient was transferred to the intensive care unit after successful resuscitation for ventricular fibrillation... The inclusion of MI as a relative or absolute contraindication for IV rtPA in acute stroke is not evidence-based., Although cardiac wall rupture and tamponade are very rare in patients presenting acute stroke and MI, these complications may constitute a major barrier for IV rtPA in such patients... However, in comparison to controls, with the exception of patients older than 75 years, the occurrence of and the risk of mortality from cardiac rupture is not increased after treatment of acute MI with rtPA. ,, There are no evidence-based guidelines for the management of patients with concomitant acute MI and acute stroke, nor are there published clinical studies addressing the decision-making process in such cases... Although superior to thrombolysis for acute MI, primary percutaneous coronary intervention would delay rtPA for stroke, increasing the risk of severe neurological disability in our case... In a patient without demographic risk factors for cardiac tamponade, we decided to offer thrombolysis in a balanced attempt to treat both myocardial and brain infarction, after excluding any relevant change on bedside transthoracic echocardiography... In conclusion, given the current knowledge limitations, treatment decisions in cases of concomitant acute MI and acute ischemic stroke should be individualized... The delicate balance between the presence or absence of risk factors for cardiac tamponade and the potential cardiac or neurological disability may guide the clinician in such a difficult scenario... Alteplase should probably not be avoided in eligible patients with ischemic stroke and MI in the absence of the aforementioned risk factors for cardiac complications associated with intravenous thrombolysis.

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(A) Electrocardiogram showing sinus rhythm, with 2:1 conduction block; two p waves (blue arrows) and one QRS wave (blue circle) are shown. ST elevation is visible in leads II, III, and aVF (red arrows), with ST depression in leads I and aVL (white arrows). (B) Brain CT showing early signs of acute stroke (insular ribbon sign and hemispheric sulcus effacement) in the right MCA territory. (C) Established stroke in the cortical territory of the right MCA. (D) Additional bilateral ischemic stroke in the posterior territory.
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Figure 1: (A) Electrocardiogram showing sinus rhythm, with 2:1 conduction block; two p waves (blue arrows) and one QRS wave (blue circle) are shown. ST elevation is visible in leads II, III, and aVF (red arrows), with ST depression in leads I and aVL (white arrows). (B) Brain CT showing early signs of acute stroke (insular ribbon sign and hemispheric sulcus effacement) in the right MCA territory. (C) Established stroke in the cortical territory of the right MCA. (D) Additional bilateral ischemic stroke in the posterior territory.

Mentions: A 44-year-old Caucasian man with a past history of binge drinking and heavy smoking since childhood, presented to the emergency department (ED) with a history of sudden onset of focal neurologic deficits, which had stared 1 hour previously. Neurological examination revealed dysarthria, left-sided homonymous hemianopia, facial central paresis, hemiparesis, and hemineglect (National Institutes of Health Stroke Scale [NIHSS] score, 11). His general examination was unremarkable. Blood pressure was 110/70 mmHg, temperature was 36.8℃, and pulse was 61 bpm. There was no jugular venous distension. He also complained of an intermittent vague ache in the anterior thoracic region and left shoulder, which had been present for the preceding 48 hours. The patient's electrocardiogram showed signs compatible with inferior MI with 2:1 atrioventricular block (Figure 1A). Cardiac troponin I level was elevated at 16.045 ng/mL (normal value, ≤0.04 ng/mL). Emergent bedside transthoracic echocardiography showed the presence of inferior wall hypokinesis with good left ventricular systolic function. Computed tomography brain scan (brain CT) showed early signs of ischemia in the territory of the right middle cerebral artery (Figure 1B).


Acute stroke with concomitant acute myocardial infarction: will you thrombolyse?

Maciel R, Palma R, Sousa P, Ferreira F, Nzwalo H - J Stroke (2015)

(A) Electrocardiogram showing sinus rhythm, with 2:1 conduction block; two p waves (blue arrows) and one QRS wave (blue circle) are shown. ST elevation is visible in leads II, III, and aVF (red arrows), with ST depression in leads I and aVL (white arrows). (B) Brain CT showing early signs of acute stroke (insular ribbon sign and hemispheric sulcus effacement) in the right MCA territory. (C) Established stroke in the cortical territory of the right MCA. (D) Additional bilateral ischemic stroke in the posterior territory.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4325641&req=5

Figure 1: (A) Electrocardiogram showing sinus rhythm, with 2:1 conduction block; two p waves (blue arrows) and one QRS wave (blue circle) are shown. ST elevation is visible in leads II, III, and aVF (red arrows), with ST depression in leads I and aVL (white arrows). (B) Brain CT showing early signs of acute stroke (insular ribbon sign and hemispheric sulcus effacement) in the right MCA territory. (C) Established stroke in the cortical territory of the right MCA. (D) Additional bilateral ischemic stroke in the posterior territory.
Mentions: A 44-year-old Caucasian man with a past history of binge drinking and heavy smoking since childhood, presented to the emergency department (ED) with a history of sudden onset of focal neurologic deficits, which had stared 1 hour previously. Neurological examination revealed dysarthria, left-sided homonymous hemianopia, facial central paresis, hemiparesis, and hemineglect (National Institutes of Health Stroke Scale [NIHSS] score, 11). His general examination was unremarkable. Blood pressure was 110/70 mmHg, temperature was 36.8℃, and pulse was 61 bpm. There was no jugular venous distension. He also complained of an intermittent vague ache in the anterior thoracic region and left shoulder, which had been present for the preceding 48 hours. The patient's electrocardiogram showed signs compatible with inferior MI with 2:1 atrioventricular block (Figure 1A). Cardiac troponin I level was elevated at 16.045 ng/mL (normal value, ≤0.04 ng/mL). Emergent bedside transthoracic echocardiography showed the presence of inferior wall hypokinesis with good left ventricular systolic function. Computed tomography brain scan (brain CT) showed early signs of ischemia in the territory of the right middle cerebral artery (Figure 1B).

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Centro Hospitalar do Algarve (CHA), Faro, Portugal. ; Stroke Unit, Centro Hospitalar do Algarve (CHA), Faro, Portugal.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Dear Sir: Concomitant occurrence of acute myocardial infarction (MI) and stroke is infrequently encountered in emergent patients... IV t-PA (0.9 mg/kg over 1 hour, total dose 80 mg) was administered 2 h after stroke onset... The patient's condition improved with thrombolysis (NIHSS score, 4)... Results of the remaining investigations, including a metabolic panel (glucose levels, hemogram, blood coagulation times, ionogram, renal function, hepatic enzymes), were normal... The patient was transferred to the intensive care unit after successful resuscitation for ventricular fibrillation... The inclusion of MI as a relative or absolute contraindication for IV rtPA in acute stroke is not evidence-based., Although cardiac wall rupture and tamponade are very rare in patients presenting acute stroke and MI, these complications may constitute a major barrier for IV rtPA in such patients... However, in comparison to controls, with the exception of patients older than 75 years, the occurrence of and the risk of mortality from cardiac rupture is not increased after treatment of acute MI with rtPA. ,, There are no evidence-based guidelines for the management of patients with concomitant acute MI and acute stroke, nor are there published clinical studies addressing the decision-making process in such cases... Although superior to thrombolysis for acute MI, primary percutaneous coronary intervention would delay rtPA for stroke, increasing the risk of severe neurological disability in our case... In a patient without demographic risk factors for cardiac tamponade, we decided to offer thrombolysis in a balanced attempt to treat both myocardial and brain infarction, after excluding any relevant change on bedside transthoracic echocardiography... In conclusion, given the current knowledge limitations, treatment decisions in cases of concomitant acute MI and acute ischemic stroke should be individualized... The delicate balance between the presence or absence of risk factors for cardiac tamponade and the potential cardiac or neurological disability may guide the clinician in such a difficult scenario... Alteplase should probably not be avoided in eligible patients with ischemic stroke and MI in the absence of the aforementioned risk factors for cardiac complications associated with intravenous thrombolysis.

No MeSH data available.


Related in: MedlinePlus