Associazione Nazionale Medici Cardiologi Ospedalieri



Concomitant Acute Coronary Syndrome and Peptic Ulcer Perforation. A dramatic life-threating combination still unresolved.

Schettino Matteo Genova(Genova) – Ospedale Policlinico San Martino | Bezante Gian Paolo Genova(Genova) – Ospedale Policlinico San Martino | Porto Italo Genova(Genova) – Ospedale Policlinico San Martino

Acute myocardial infarction with ST-segment elevation (STEMI) and ulcer peptic perforation are two different conditions that could manifest at the same time. We reported a 79-year-old Caucasian man with hypertension, dyslipidemia and CAD (previous stenting on RCA and LAD) with chest pain, vomiting and tarry stool, with normal vital signs. ECG: ST-segment elevation in inferior leads. Hemoglobin: 7.4 g/dl. TnI: negative. The Chest X-ray was normal. The coronary angiography showed a multivessel disease with a sub-occlusion of RCA, a restenosis borderline of LAD and a critical stenosis of OM. Multiple dilatations on culprit lesion with balloon were performed. There was a regression of the ST-segment elevation in the inferior leads, so the interventional cardiologist decided not to stent the vessel. After PCI, clopidogrel loading dose 600 mg was prescribed and two blood transfusions were administered. The echocardiography showed a mildly reduced ejection fraction with abnormalities of inferior, posterior and lateral walls. Subsequently, the patient was stable, asymptomatic with normal vital signs but, progressively, the blood pressure dropped, and the patient became tachypnoic. The echocardiogram showed micro-bubbles moving in all the left and right cardiac chambers. Chest X-ray showed subdiaphragmatic free air and CT demonstrated free intraperitoneal air and air inside the systemic and portal venous circulation, suggesting a perforated viscus. The patient was transferred directly to the operating room in unstable hemodynamic condition, and there for the first time he complained abdominal pain. During surgery the perforation was found in the first segment of the posterior region of duodenal tract and, because of unstable clinical conditions, a conservative treatment was made with a Petzer sound’s application and a plastic of the perforation with stitches and omentoplasty. The patient passed away three days later because of sepsis.

The concomitant presence of STEMI and peptic ulcer perforation is rare, but possible event. In our case it might have been reasonable not to give the DAPT or to halve the loading dose, but this has not been supported by clinical studies. There are no clear guidelines or algorithms to choose what to treat first, and up to now the patient’s management depends on the clinical presentation and the algorithms used in clinical practice are those defined by the 112 staff together with the Emergency Department teams.