Simultaneous ST-Elevation Myocardial Infarction and Ischemic Stroke: A Therapeutic Dilemma and a Case for Deferred Revascularization

The simultaneous occurrence of acute ischemic stroke and ST-elevation myocardial infarction (STEMI), termed cardio-cerebral infarction (CCI), represents a rare and challenging emergency due to competing therapeutic priorities. No clear guidelines currently exist to guide management in such cases. A 63-year-old male with uncontrolled hypertension presented with 48 hours of progressive dyspnea and epigastric discomfort, followed by sudden-onset left hemiplegia and dysarthria. On admission, brain CT revealed a right middle cerebral artery infarction without hemorrhage. ECG showed inferior STEMI, and troponin levels were elevated. Given the high hemorrhagic risk, urgent coronary angiography was deferred. A conservative strategy was adopted with aspirin (75 mg/day) and intermediate-dose low-molecular-weight heparin (enoxaparin 40 mg BID), initiated within six hours of neuroimaging. The patient’s neurological status gradually improved, with National Institutes of Health Stroke Scale scores decreasing from 17 at admission to 10 at discharge, and a modified Rankin Score of 3. One month later, he reported recurrent angina. Coronary angiography revealed spontaneous reperfusion of the right coronary artery, allowing successful percutaneous coronary intervention with three stents. This case illustrates a stroke-first approach based on neurologic severity and hemodynamic stability. Antithrombotic management balanced ischemic and hemorrhagic risks. Timely neurologic improvement allowed deferred but successful revascularization, emphasizing the importance of individualized care in CCI.