Critical Care Medicine-Neurologic Disorders>>>>>Acute Coronary Syndrome
Question 6#

A 57-year-old male with a history of hyperlipidemia is admitted to the intensive care unit with hypotension necessitating vasopressor support. He had been in his usual state of health, but in the preceding 24 hours, he developed progressively worsening dyspnea, culminating in respiratory failure and necessitating intubation.

His admission electrocardiogram is shown below:

His presenting troponin-T is 2.52 ng/mL (reference <0.03 ng/mL). Shortly after admission, the patient is witnessed to have repeated episodes of self-terminating ventricular tachycardia, the longest of which last up to 45 seconds.

An echocardiogram is performed and demonstrates severe biventricular dysfunction with an estimated left ventricular ejection fraction of 12%.

Which of the following would be the most appropriate next step in management?

A. Urgent coronary angiography with the intent to revascularize
B. Insertion of a percutaneous left ventricular assist device (LVAD)
C. Insertion of an intra-aortic balloon pump (IABP)
D. Cardiac biomarker panel

Correct Answer is A

Comment:

Correct Answer: A

The patient presents with rapidly decompensating heart failure leading to cardiogenic shock. His 12-lead electrocardiogram reveals Q-waves consistent with old inferior, anteroseptal and anterior wall infarction, suggesting that ischemia may be related causally to the biventricular dysfunction. While consideration of ventricular support devices in this case is important, a univentricular support device, such as an IABP or percutaneous LVAD, would likely be inadequate in the presence of biventricular failure. Furthermore, there is minimal evidence in favor of IABP or PVAD in cardiogenic shock. His ventricular arrhythmias are likely a consequence of the acute decompensation on the background of severe biventricular cardiomyopathy.

Immediate diagnostic angiography with intent to perform revascularization is indicated in patients with non-ST elevation myocardial infarction (NSTEMI) who have refractory angina or hemodynamic or electrical instability. Acute myocardial infarction is the leading cause of cardiogenic shock and early revascularization is associated with improved mortality when compared to medical therapy. Mortality nevertheless remains high in this subset of patients. In patients for whom percutaneous coronary intervention may not be possible or for whom a mechanical complication of myocardial infarction is present, coronary artery bypass grafting can be considered.

References:

  1. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;64(24):e139-e228.
  2. Jeger RV, Urban P, Harkness SM, et al. Early revascularization is beneficial across all ages and a wide spectrum of cardiogenic shock severity: a pooled analysis of trials. Acute Cardiac Care. 2011;13(1):14-20.