P456 SUBACUTE STEMI AND ISCHEMIC STROKE DURING SARS–COV2 INFECTION: A CASE REPORT

Abstract

Abstract A 71–year–old woman arrived in the ER for left hemiparesis and dysarthria. The Patient was oriented, collaborative. Stable hemodynamics. Left hemiparesis. Dysarthria. NIHSS 8, Ranking 2. Blood tests, EGA, swab for SARS–Cov2 were performed (hsTnI 9433 ng, PCR 15.6 mg/dl, Sars–Cov2 positive test). ECG showed evidence of inferolateral ST–segment elevation with Q waves in the inferior site and negative T waves in the inferolateral leads. An episode of chest pain radiating to the left upper limb two days ago was reported. The echocardiography showed non–dilated left ventricle with global systolic function at the lower limits. Inferior, infero–lateral and medio–basal akinesia with hyper–refractive wall and preserved thicknesses were found. Moreover, a slight layer of circumferential pericardial effusion, without any hemodynamic importance was showed. In order to exclude an aortic syndrome, a CT angiography of the brain, neck and chest was performed for recent lesions, with negative result. Angiography showed the left vertebral artery up to the V3 segment, suspected by dissection. Recommendations on performing fibrinolysis in adults, with concurrent ischemic stroke and subacute STEMI, are conflicting: according to ASA/AHA guidelines in recent 3–month infarction, treatment is reasonable if the inferior or right wall is involved. According to ESO guidelines, fibrinolysis is not recommended if the subacute STEMI is seven days old. The Italian guidelines consider the treatment of acute stroke with r–TPA with subsequent PTCA, with possible stent, and recognize a very low risk of consequent hemopericardium. Depending on the timing of the anginal symptoms, the presence of Q waves on the ECG and the echocardiographic alterations, the AMI was considered subacute with no indication for urgent coronary angiography. For the patient of this case report, a conservative attitude for both pathologies was decided, performing an antiplatelet therapy with ASA and continuous ECG monitoring. Despite the treatment, the patient suffered heart failure and exitus after 10 days hospitalization. The lack of unequivocal guidelines on the treatment of patients with simultaneous ischemic stroke and subacute STEMI, require careful evaluation of the individual case, searching for possible predisposing factors of a poor prognosis.