Introduction: Diabetes mellitus is a major risk factor for the occurrence of cardiovascular ischemic events. A particular feature of diabetic patients is the high rate of atypical angina pain, which may lead to late diagnosis of acute coronary syndromes.

Case presentation: A 60 years old male patient, hyper-tensive, active smoker (40 P-Y), known with diabetes mellitus type 2 in treatment with oral hypoglicemic agents (~10 years), presents in emergency room for ri-ght hemiparesis with a sudden onset 60 minutes befo-re admission. The patient reports an episode of resting dyspnea 2 weeks prior, lasting 6-7 hours. On clinical examination, the patient is conscious, aware, but has a motor and sensory deficit on the ri-ght side and a positive Babinski sign. He is overweight (BMI=28), with high blood pressure (150/100mm Hg), HR 90/min, regular pulse, without any cardiac mur-mur. T he blood workup revealed a normal CK-MB level land slightly increased high-sensitive troponin over the MI cut-off (120 ng/L), hypercholesterolemia, hyperglycemia (180mg / dL) and increased HbA1c (8%). ECG – sinus rhythm, HR 95 / min, Q wave, ST eleva-tion of maximum 2 mm and negative T waves in V2-V4 suggesting subacute MI. Echocardiography – left ven-tricular apical aneurysm, LVEF 30% and a large throm-bus lining the LV apex, with multiple mobile images at this level. The brain CT revealed signs of acute ische-mia in the left mid cerebral artery and no hemorrhage. The patient is diagnosed with cardioembolic ische-mic stroke and subacute myocardial infarction that probably occurred two weeks prior. Despite the early presentation, recent myocardial infarction is a contraindication for thrombolysis in pa-tients with acute stroke, so mechanical thrombectomy was performed by the interventional radiologist, with a good result. Regarding the treatment, the patient recei-ved dual antiplatelet therapy, a beta blocker, ACE inhi-bitor, MR antagonist and high dose statin. Considering the clinical and the CT examination, the risk of hemor-rhagic transformation was evaluated as medium. Given the presence of extensive thrombosis at the apical LV level, the patient also received low molecular weight heparin for 7 days, followed by non-AVK oral anticoagulation. The coronary angiogram was not con-sidered necessary (the patient had no signs of resting heart failure, with an apical aneurysm complicated with thrombus and late presentation MI). The patient had a slight but progressive sensory and motor reco-very, and was included in an early post-stroke recovery program. After hospital discharge, in the absence of percutaneous coronary intervention, dual association (clopidogrel + acenocoumarol – with a target INR of 2-3) was recommended. The patient will be evaluated at 1, 3 and 6 months for the LV apical thrombosis and to establish the duration of long-term oral anticoagu-lation. Also, it might be necessary to study the viability and the residual myocardial ischemia in the territory of the anterior interventricular artery in order to assess the possibility of a revascularization procedure.

The particularity of the case: The particularity of this case is represented by the late diagnosis of myocardial infarction which was revealed by a severe neurological complication, a consequence of the apical thrombosis LV.

Conclusions: The case presented draws attention to the particularities of ischemic heart disease in the diabetic patient, a high clinical suspicion being necessary to es-tablish the early and correct diagnosis. Also, diabetic patients should be informed and trained to recognize the atypical symptoms of acute coronary syndromes, and in case these symptoms occur, they should imme-diately present in the Emergency Department.