APCU25MPB1 The diver’s infarct: an unusual cardiac manifestation of decompression sickness

Introduction Cardiovascular manifestations decompression sickness (DCS) are rare and such cases are easily mistaken for acute coronary syndromes (ACS), risking unnecessary interventions. Here, we report a case of DCS presenting as late presentation Anterior MI in a professional diver.Case Presentation A 46-year-old Malay male professional diver developed acute left-sided chest discomfort five days after completing five consecutive deep-sea dives to a depth of approximately 120 feet. An ECG on arrival showed QS complexes with ST-segment elevation (STE) in V1–V3 and T-wave inversion in V4–V6, suggestive of a late presentation of anterior MI. Troponin T was elevated at 730 ng/L. An initial echocardiogram showed a left ventricular ejection fraction (LVEF) of 36% with hypokinesia in the LAD territory. Initially, he was treated for NSTEMI, but his condition deteriorated, with recurrent episodes of chest pain and a new onset of a right middle cerebral artery (MCA) infarct related to a small left ventricular (LV) thrombus. Immediate cardiac intervention was declined due to the recent ischemic stroke. A revised decision was made to recompress him based on the initial history suggestive of DCS. He underwent two sessions of hyperbaric oxygen therapy (HBOT), with marked improvement in symptoms. A follow-up echocardiogram four weeks later showed recovery of LVEF to 74% with resolution of the LV thrombus. His ECG normalized with the disappearance of Q waves, despite no coronary intervention having been performed.Discussion Cardiac involvement in DCS is rare and underreported. The likely pathophysiologic mechanisms include intravascular nitrogen bubble embolization within coronary arteries, paradoxical embolism through a patent foramen ovale, or endothelial dysfunction leading to transient coronary occlusion. In such scenarios, conventional ACS management strategies, such as thrombolysis or urgent angiography, may not only be inappropriate but also delay definitive therapy. HBOT is the mainstay of treatment, as it reduces bubble size, improves oxygen delivery, and mitigates further ischemic injury.Conclusion In divers with chest pain, clinicians should consider DCS as a differential diagnosis. Prompt recognition and hyperbaric oxygen therapy can result in full recovery and prevent mismanagement even though the clinical decision-making can be challenging.