Hypertensive Cardiogenic Shock Due To Stress-induced Cardiomyopathy
Presenter
Khaled Shunnar, MBBS, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
Khaled Shunnar, MBBS, Mohanad Shehadeh, M.D. and Abdulrahman Arabi, MD, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
Title
Hypertensive Cardiogenic Shock Due To Stress-induced Cardiomyopathy Introduction
Cardiogenic shock (CS) may present with normal systolic pressure, however, persistent hypertension is rare in CS. We present a case of profoundly compromised tissue perfusion and reduced cardiac output while maintaining high systemic blood pressure.
Clinical Case
A 59-year-old female with a past medical history of end-stage renal disease was admitted with anemia and suspected sepsis. On Day 2 of admission, following blood transfusion, she suffered from PEA cardiac arrest. There was new ECG changes on post return to spontaneous circulation. Despite high blood pressure before and after the event, she had severe lactic acidosis. An echocardiogram revealed an ejection fraction of 35%, dropping from 61% at baseline, with akinetic apex and hypokinetic remaining segments. Stroke volume (SV) and cardiac output (CO) were estimated at 51 ml and 4.59 L/min, respectively. She was started on dobutamine and isosorbide dinitrate infusions. She required continuous hemodialysis to correct metabolic acidosis. A follow-up echocardiogram after 48 hours showed worsening hemodynamics, with SV 28 ml and CO 3.11 L/min. Hence, milrinone was initiated.Right heart catheterization was performed, findings are shown in table 1. Coronary angiography revealed non-obstructive coronary artery disease. The left ventriculogram showed akinetic apex with preserved basal segment function, consistent with stress-induced cardiomyopathy. There was evidence of severe mitral regurgitation. Vasodilator therapy was maximized with high dose nitrate infusion and intravenous hydralazine. Milrinone and dobutamine were weaned off, and lactic acidosis resolved.
| | Baseline | After 4000 mcg IV nitroglycerin |
| BP (mmHg) | 154/97 | 147/106 |
| PCWP (mean, mmHg) | 39 | 30 |
| LVEDP (mmHg) | 42 | 31 |
| CO (L/min) | 2.20 | 2.51 |
| CI (L/min/m2) | 1.42 | 1.62 |
| SVR (Wood units) | 44.5 | 49 |
Table 1: Invasive hemodynamic parameters before and after the administration of nitroglycerin. IV: intravenous BP: Blood Pressure; PCWP: Post-Capillary Wedge Pressure; LVEDP: Left Ventricular End-Diastolic Pressure; CI: Cardiac Index; SVR: Systemic Vascular Resistance.
Discussion
Cardiogenic shock (CS) can present with normal or high blood pressure (BP). CS without hypotension was reported in almost half of the patients with acute myocardial infarction (AMI). These patients had an overall better prognosis compared to patients with classic CS. In scenarios other than AMI, as in our patient, timely recognition of CS despite having normal or high BP is paramount. Invasive hemodynamic assessment is key to confirming the diagnosis and guiding further management.