Silent acute STEMI associated with alcohol withdrawal in a 46-year-old male: a case report

Introduction and importance: Alcohol withdrawal (AW) results from abrupt cessation or reduction in chronic alcohol use, leading to central nervous system hyperexcitability and autonomic overactivity. AW poses significant cardiovascular stress, predisposing to myocardial ischemia via various mechanisms. Case presentation: A 46-year-old male with chronic heavy alcohol use and no known major cardiovascular risk factors presented with restlessness. On admission, he exhibited features of moderate alcohol withdrawal, including tremors, agitation, and disorientation. He was managed supportively in the intensive care unit with a titrated diazepam infusion, resulting in gradual improvement in withdrawal symptoms. On the 10th day, a routine ECG demonstrated an acute inferior wall ST-elevation myocardial infarction (STEMI), and the qualitative troponin I test was positive, despite the absence of ischemic symptoms. Clinical discussion: The underlying mechanism of myocardial infarction could not be definitively established because coronary angiography was declined. Although recent alcohol withdrawal may have contributed through persistent physiological stress, coronary artery vasospasm, myocardial oxygen supply-demand mismatch, platelet hyperactivity, or other mechanisms remain possible. The patient was fully oriented at the time of infarction, supporting the diagnosis of a silent myocardial infarction. Conclusion: This case report adds to the scarce literature on acute coronary events during hospitalization for severe alcohol withdrawal and emphasizes that the patient’s silent STEMI may have arisen from multiple underlying mechanisms. It highlights the importance of maintaining a high index of suspicion for silent myocardial infarction in hospitalized patients recovering from alcohol withdrawal.