2017 Resarch Forum

EM: C-1 Applicant: Jing Liu MD

Acute myocardial infarction with simultaneous gastric perforation Alon Kaplan MD 1 , Dan Schwarzfuchs MD 1 , Vladimir Zeldetz MD 1 , Jing Liu MD 2 1 Soroka University Medical Center 2 Kern Medical

INTRODUCTION: Acute myocardial infarction and perforated peptic ulcer disease with associated peritonitis are two disease processes that both require emergent intervention and rarely occur simultaneously. PURPOSE: A 66 y/o female with untreated type 2 diabetes mellitus and hypertension was found to have electrocardiographic (EKG) changes consistent with acute ST-segment elevation myocardial infarction (STEMI) as well as a physical exam consistent with an acute abdomen. CT imaging showed free air in the abdomen suggesting hollow viscus perforation. After a multidisciplinary discussion between emergency medicine, internal medicine, and surgery, the decision was made to proceed with percutaneous coronary intervention (PCI) prior to laparoscopic surgery. The patient was found to have a 99% occlusion of the right coronary artery and a bare metal stent was successfully placed. The patient was transferred to the operating room for laparoscopic surgery which revealed a 2mm perforation of the prepyloric gastric antrum. The perforation was repaired however the patient became hemodynamically unstable at this time requiring high dose vasopressors. A repeat PCI was performed demonstrating early subacute stent thrombosis. The thrombus was partially evacuated and an additional stent was placed, however the patient expired in the cardiac critical care unit shortly afterwards. DISCUSSION: While STEMI can manifest clinically with epigastric complaints, perforated viscus may also have accompanying ischemic changes on EKG. There is limited research regarding the two disease processes occurring simultaneously, and cardiac pathology may be easily missed without high clinical suspicion. There is mixed evidence regarding whether to proceed with surgery or PCI first given this scenario, however there is extensive literature suggesting that early PCI in the setting of STEMI has improved outcomes. Studies suggest that cardiac catheterization within 90 minutes is associated with lower rates of in hospital mortality as well as decreased mortality at 30 days as well as 1 year. Perforated peptic ulcer disease has been demonstrated to have a mortality rate of approximately 10%, and a delay in treatment over 24 hours from time of symptom onset has been established as an independent predictor of 30 day mortality. CONCLUSION: In patients found to have concurrent medical emergencies, recognition of all relevant disease processes is crucial. Determining the most effective sequence of treatment is not always readily apparent. Multidisciplinary discussions may aid in deciding how to proceed however a clearly established algorithm may facilitate the treatment of these patients.

Figure: PCI shows an occlusion in the RCA