INFLAMMATORY STATE AS A CAUSE OF STEMI IN A PATIENT PRESENTATION WITH DKA

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: One of the major complications of diabetes mellitus includes hypercoagulability due to platelet hyperactivity, coagulation activation, and hypofibrinolysis. Acute hyperglycemia is hypothesized to exacerbate the coagulation pathway by enhancing the activities of factor VII, VIII and tissue factor pathway inhibitor. The prothrombic state observed in diabetic ketoacidosis (DKA) is due to endothelial activation, augmented activity of platelets, and increased concentration of von Willebrand factor. In the case of inflammatory bowel disease (IBD), however, thrombotic events occur due to an increase in coagulation factors including factor V, VII, VIII, prothrombin, and the thrombin-antithrombin complex. Other studies have noted that the decrease in factor XIII in active Crohn's disease is related to consumption of factor XIII in forming microthrombis. We are presenting a unique case of a STEMI that was provoked by the presence of two hypercoagulable disorders, IBD and DKA. CASE PRESENTATION: The patient is a 41-year-old male with significant PMH of type I diabetes mellitus complicated by gastroparesis and multiple admissions for diabetic ketoacidosis, as well as Crohn's disease not on immunosuppressive therapy. The patient presented with a chief complaint of intractable nausea, vomiting and diffuse, non-radiating abdominal pain. On admission, he was tachycardic, tachypneic, and normotensive. His laboratory studies were consistent with DKA. Abdominal X-ray showed fluid distension in the stomach, similar to previous CT abdomen findings, coinciding with his significant history of gastroparesis. EKG revealed ST elevations in leads II, III, aVF and V3-V6. He underwent a cardiac catheterization, which revealed thrombus in the proximal segment of the right coronary artery with no obvious underlying coronary artery disease. He underwent mechanical thrombectomy only, with no stent deployed. The patient was discharged with goal-directed medical therapy and to continue dual-antiplatelet therapy for one year. DISCUSSION: DKA can cause various complications including hypercoagulability. There are proposed hypotheses for risk of developing thromboembolic disease in both DKA and IBD. The patient had a significant history of recurrent admissions due to DKA with non-specific EKG changes. The patient in this case had a history of Crohn's disease, and was not on any immunosuppressive medications. If the patient's comorbidities had been better controlled, it is possible that the patient would not have suffered this STEMI. CONCLUSIONS: The patient had two hypercoagulable disorders that could have led to formation of the intracoronary thrombus. This case demonstrates the importance of management of chronic diseases and their effects on other organ systems. REFERENCE #1: Hazan, Tal, et al. "Hypercoagulability in Crohn's Disease: a Complex Pathology: ... : Official Journal of the American College of Gastroenterology: ACG." LWW, Sept. 2008, journals.lww.com/ajg/fulltext/2008/09001/hypercoagulability_in_crohn_s_disease__a_complex.1104.aspx. REFERENCE #2: Giannotta, Martina, et al. "Thrombosis in Inflammatory Bowel Diseases: What's the Link?" Thrombosis Journal, BioMed Central, 2 Apr. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4393581/. REFERENCE #3: Lemkes, BA, et al. "Hyperglycemia: a Prothrombotic Factor?" Journal of Thrombosis and Haemostasis : JTH, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/20492456/. DISCLOSURES: No relevant relationships by Saad Chaudhry, source=Web Response No relevant relationships by Mary Dickow, source=Web Response No relevant relationships by Kristen Hughes, source=Web Response No relevant relationships by Zaid Kasmikha, source=Web Response No relevant relationships by Verisha Khanam, source=Web Response