Acute ST-Segment Elevation Myocardial Infarction (STEMI) in a Teenager with Dilated Cardiomyopathy (DCM) and CKD

Introduction: STEMI is exceedingly rare in pediatric patients, particularly in those with no atherosclerotic risk factors. This case highlights a rare occurrence of STEMI in a teenage girl with pre-existing DCM and advanced CKD, and discusses diagnostic and management challenges in this high-risk subgroup. Case Description: A 16/F with PMH Stage 4 CKD secondary to neurogenic bladder (from repaired meningocele) and DCM (EF 30%) presented to the ER with acute-onset chest pain, dyspnea at rest, diaphoresis, and emesis. Stable vitals, sPO2 90% on RA, bibasilar crepitations on physical exam. Pertinent labs: Creatinine 3.5 mg/dL, BUN 128 mg/dL, no dyslipidemia. Urinalysis: 2+ protein, 2-3/hpf WBC, 4-5/hpf RBC. EKG showed ST elevations in leads V4-V6 with elevated high-sensitivity cardiac troponin I (hs-cTnI) of 43 pg/mL. Echo confirmed very low EF 15–20% with dilated LV with global LV hypokinesis, no RWMA, and grade I diastolic dysfunction. The patient was diagnosed with Acute Lateral wall STEMI with LVF superimposed on known DCM and CKD, and was given thrombolysis with IV Streptokinase due to our resource-constrained setting, along with DAPT, IV UFH, and supportive treatment. The patient was discharged on GDMT for heart failure and MI. Patient underwent coronary angiography at outside hospital that revealed LCx occlusion with diffuse LAD and RCA disease, but refused PTCA and was discharged on medical management. Discussion: Children with CKD are the pediatric population with highest cardiovascular risk. The striking absence of both traditional (hypertension, dyslipidemia, hyperglycemia) and uremic risk factors (hyperparathyroidism, increased calcium-phosphorus product, elevated CRP) makes this presentation unique and poses management challenges for risk factor reduction. Symptomatic CAD is rarely noted in children with CKD (mostly manifests in young adults). CVD is the leading cause of death in both adults and children with CKD, with cardiac arrest, arrhythmias, and cardiomyopathy being most common, and MI rarely reported in children, thereby making our case unique. We didn’t find any documented evidence of STEMI in pediatric CKD patients with DCM. Aggressive monitoring and management of traditional and uremia-related risk factors is of paramount importance, and decreasing time spent on dialysis with early transplant can help reduce CVD morbidity and mortality.