P1259 When it rains, it pours: Late presentation STEMI in a patient with intricate symptomatology due to concomitant acute pancreatitis and pneumonia

Abstract

Abstract Background ST segment elevation acute myocardial infarction and acute pancreatitis are diagnostic and therapeutic emergencies. The concomitance of these two pathologies produces intricate and confusing symptoms leading to late presentation. Clinical Case Description- We present the case of a 62-year-old male patient, non-smoker, admitted in the emergency department for intense, continuous epigastric pain with posterior radiation and dyspnea, started four days before. On admission we found hemodynamic stability, lung crackles in the ½ inferior of the right lung, SaO2= 94% under 3l/min O2, normal cardiac sounds, HR 102/min, mitral systolic murmur, BP 145/80mmHg, abdominal pain on palpation. Lab tests revealed elevated cardiac troponin values and detection of a fall of cTn values in dynamics (hs-cTnI 30372ng/l, TnI 73ng/ml), but also high serum transaminases, amylase and lipase (1278 U/l), with high inflammatory markers, leukocytosis and neutrophilia. ECG showed sinus rhythm, QRS axis 0 degrees, ST segment elevation in V1-V4, ST segment depression DI, aVL, negative and biphasic T waves in V5-V6, DI, DII, aVL, Q wave in DIII, aVF and poor R wave progression V1-V4. Admission echocardiography revealed dilated left cavities with severe left ventricular systolic dysfunction (EF 20%), akinesia of the anterior and inferolateral walls, moderate mitral and tricuspid regurgitation, grade III diastolic dysfunction and possible pulmonary arterial hypertension. Coronary angiography revealed distal stenosis of the left main, involving the bifurcation, 80% ostial LAD stenosis, proximal LAD occlusion, 30% ostial LCX. PCI with DES of the proximal LAD, and left main–LDA junction with overlapping was performed successfully. Abdominal echography showed increased volume of the pancreas and significant decrease in echogenicity. Abdominal CT scan assessed inflammatory changes in pancreas and peripancreatic fat (grade C Balthazar score), superior mesenteric artery partial thrombosis and alveolar consolidation in the right lung. Echocardiography reassessment four days later revealed a fresh apical thrombus of the left ventricle. He received treatment with low molecular weight heparin, dual antiplatelet therapy statin, loop diuretic, aldosterone antagonist, digoxin, antibiotics and food restriction with gradual oral realimentation. He needed positive inotropic support for the first 4 days from a total of 28 days of hospitalization. Conclusions ECG changes and prothrombotic status can occur in patients with acute pancreatitis. The diagnosis and management of STEMI concomitant with acute pancreatitis can be challenging. The multimodality imaging and interdisciplinary approach individualized to the patient’s clinical situation is important, especially when having safety concerns about the revascularization therapy, antiplatelet and anticoagulant therapy. Abstract P1259 Figure.