A Rare Complication of Ulcerative Colitis: ST Elevation Myocardial Infarction

Abstract

Purpose: A 44-year-old female presented to the emergency room (ER) with sudden onset substernal chest pain. The patient had no known cardiac risk factors. She had a history of Ulcerative Colitis (UC), which had been in remission until two days prior to the presentation, when she started having abdominal pain and bloody diarrhea. This episode was similar to her prior exacerbations but she was currently not on any treatment. The physical exam was only remarkable for mild diffuse tenderness in the abdomen. The EKG done in the ER showed ST segment elevations in leads II, III and aVF and the lab work was significant for elevated cardiac enzymes (Troponin I-25 ng/ml). The patient underwent an urgent cardiac catheterization which revealed total occlusion of the right coronary artery. The artery could not be stented due to the presence of extensive thrombus and even though, thrombectomy was attempted, it was not successful. The decision was made to manage the patient medically and she was started on a beta blocker, ACE inhibitor and statin for acute MI and mesalamine for Ulcerative colitis exacerbation. Aspirin and Clopidogrel were held in the light of bloody diarrhea but it was decided to start intravenous heparin. The patient responded well to the treatment. The hematocrit remained stable and there were no further episodes of bleeding. She was eventually discharged in a stable condition. Ulcerative colitis is frequently associated with many extra-intestinal manifestations, mostly in the form of dermatological, hepatobiliary or ocular involvement but cardiac involvement is rare. It usually manifests as either pericarditis with or without myocardial involvement or conduction abnormalities. Myocardial infarction, as seen in our patient, is an extremely rare complication of Ulcerative colitis. The hypercoagulable state in UC is postulated to be due to increased levels of platelets, prothrombin fragment, fibrinogen, homocysteine and reduced levels of anticoagulants. These alterations in the coagulation cascade can result in deep venous thrombosis, pulmonary embolism, atrial thrombi and rarely coronary artery thrombosis. Interestingly, intravenous heparin has been suggested as a treatment for UC exacerbation along with standard therapy, with no increase in the incidence of bleeding. The exact mechanism by which heparin ameliorates the exacerbation is still unclear but it makes it particularly beneficial in the setting of a MI. We would like to conclude that physicians should be aware of this rare complication of Ulcerative colitis and it is important to recognize chest pain during UC exacerbation as it can indicate an impending Myocardial Infarction.