Simultaneous Myocardial Infarction and Brain: A Diagnostic and Therapeutic Challenge

Ischemic cerebrovascular event (CVD) and acute myocardial infarction (AMI) are two of the leading causes of morbidity and mortality worldwide, together accounting for more than a quarter of global deaths. Both entities share risk factors, pathophysiological mechanisms and, in some cases, a close temporal relationship. Although they usually occur independently, they can rarely occur simultaneously or in a short interval of time, configuring the so-called cardio-cerebral infarction (CHF), a rare but highly serious clinical entity.CHF is defined as the concomitant or close sequential occurrence of a cerebral ischemic event and a cardiac ischemic event. Since its initial description, its epidemiology has been difficult to establish due to its low incidence and the limited evidence available, based mainly on reports and case series. Observational studies have reported variable incidences, with rates of stroke associated with AMI between 4% and 29%, and of AMI after stroke between 0.8% and 15%. Synchronous presentation is even more infrequent, with reported incidences close to 0.009% in some series, although it can reach up to 0.5–2% in recent population records.Several pathophysiological mechanisms have been proposed to explain this association, including the formation of mural thrombi after AMI, atrial fibrillation as a source of cardioembolic embolism, paradoxical embolism through a patent foramen ovale, aortic dissection, and severe hemodynamic alterations. It has also been described that lesions in the insular cortex can induce autonomic dysfunction and adverse cardiac events.From a clinical point of view, CHF represents a significant diagnostic and therapeutic challenge, as cerebral and coronary reperfusion strategies may conflict, particularly in the use of systemic thrombolysis or endovascular interventions. The absence of specific clinical guidelines and clinical trials limits decision-making, forcing an individualized approach based on clinical experience.In this context, we present the case of a patient with simultaneous cardio-cerebral infarction associated with atrial fibrillation, complicated with hemorrhagic transformation after intravenous thrombolysis, with the aim of highlighting the diagnostic, pathophysiological, and therapeutic challenges of this complex entity.