Simultaneously Presented Acute Ischemic Stroke and Non-ST Elevation Myocardial Infarction in a Patient with Paroxysmal Atrial Fibrillation
A 58-year-old man was admitted to our emergency department because of altered mental state. He had lived alone and his neighbor discovered him lying in his room unconscious. Therefore, the precise time of the event was unclear. He had no previous history of medical illness. His initial blood pressure was 114/57 mm Hg, heart rate 110 per minute, respiratory rate 24 breaths per minute and body temperature was 35.8℃. On neurologic examination, he showed global aphasia and right sided weakness. His initial electrocardiogram showed sinus tachycardia (). However, serial electrocardiograms demonstrated paroxysmal atrial fibrillation with intermittent rapid ventricular response (). His initial creatine kinase-MB (CK-MB) was mildly elevated at 14.6 ng/mL (upper normal limit: 3.6 ng/mL) and troponin I was within the normal range at 0.11 ng/mL (upper normal limit: 0.5 ng/mL). Brain magnetic resonance imaging and angiography showed a large infarction in the left basal ganglia area due to total occlusion of the left middle cerebral artery (). Three-hundred mg of aspirin was loaded. Because of lack of information about the stroke onset time and the possibility of hemorrhagic conversion, thrombolysis and anticoagulation therapy were not considered initially. Four hours after admission, newly appeared 2-mm ST-segment depression in the V 3-6, II and aVf leads was noticed in his electrocardiogram () and the cardiac enzymes were elevated: CK-MB increased to 55.7 ng/mL and troponin I increased to 3.86 ng/mL. Blood pressure dropped to 71/53 mm Hg. A clopidogrel loading dose of 600 mg was given, and emergent coronary angiography was performed. The left coronary angiogram showed a large thrombus located at the bifurcation of the septal branch of the left anterior descending artery (). There was no significant stenotic lesion in other coronary arteries. Repeated thrombectomy with an aspiration catheter was tried, but thrombus aspiration failed. Direct stenting with a drug-eluting stent (Nobori, 3.5×24 mm; Terumo Corporation, Tokyo, Japan) was performed. After stenting, the coronary angiogram showed no residual thrombus and good distal coronary flow (). He was stable after the procedure. His electrocardiogram after stent implantation showed sinus rhythm with normalized ST-segments (). Both transthoracic and transesophageal echocardiographic examinations were performed on the next day after percutaneous coronary intervention. His left ventricular systolic function was good and there was no regional wall motion abnormality on transthoracic echocardiography. There was no thrombus in both cardiac chambers on transesophageal echocardiography.