Concurrent acute myocardial infarction and acute ischemic stroke in a diabetic patient undergoing chemotherapy for non-Hodgkin lymphoma: Should I administer thrombolytic therapy? A case report.

Background: Concurrent ST-elevation myocardial infarction (STEMI) and acute ischemic stroke (AIS) are extremely rare, and their management remains perplexing due to the absence of high-quality evidence and limited resources. For the first time, we report a rare, preventable, and suboptimally managed case of concurrent AIS and STEMI in a patient with non-Hodgkin lymphoma (NHL) who received cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) chemotherapy.

Case presentation: A 59-year-old postmenopausal woman of African origin with a background history of type 2 diabetes mellitus presented to the Jakaya Kikwete Cardiac Institute with sudden onset of left-sided weakness and typical ischemic chest pain for 3 days. The patient was recently diagnosed with NHL and started CHOP chemotherapy 3 weeks prior. Physical examination revealed left-sided hemiplegia. Emergency brain computed tomography and 12-lead echocardiography (ECG) revealed AIS and STEMI, respectively. A diagnosis of concurrent AIS and STEMI was reached, and the patient was loaded with dual antiplatelets and heparin and rushed for emergency coronary angiography (GAG) and percutaneous coronary intervention (PCI). CAG revealed massive thrombotic occlusion of the mid-segment of the left anterior descending coronary artery (mLAD) and proximal segment of the right coronary artery. Revascularization was achieved in both vessels with a resultant TIMI flow grade of 3. The post-PCI period was marked by significant improvement in chest pain and resolution of ST-elevation, as revealed by 12-lead ECG. However, the patient remained hemiplegic.

Conclusion: We have described a rare case of concurrent AIS and STEMI in a postmenopausal woman who had a significant risk of thromboembolism. The patient had uncontrolled type 2 diabetes and received CHOP chemotherapy for NHL, which was diagnosed 3 weeks prior. This case underscores the need for thromboembolic prophylaxis for selected cancer patients receiving chemotherapy. The need to individualize management is also emphasized, as both PCI and thrombolysis carry the risk of serious repercussions. In our patient, if thrombolysis was attempted it would have caused myocardial rupture and immediate death. The patient would have benefited from endovascular mechanical embolectomy for AIS; however, this practice is lacking at our institution. This calls for the establishment and strengthening of neurointerventional practices in our tertiary healthcare facilities.