2023 SCAI SHOCK

Cardiogenic Shock from Chronic Heart Failure Complicated by Embolic STEMI

Presenter

Alexander Warner, M.D., Augusta University Medical Center, North Augusta, SC
Alexander Warner, M.D., Augusta University Medical Center, North Augusta, SC

Title

Cardiogenic Shock from Chronic Heart Failure Complicated by Embolic STEMI

Introduction

With emerging evidence of cardiogenic shock phenotypes from myocardial infarction vs. chronic heart failure, we present a case of a 34-year-old female who initially presented in cardiogenic shock from chronic heart failure complicated by embolic STEMI from LV thrombus.

Clinical Case

34-year-old female with a prior history of left MCA CVA and chronic systolic heart failure who presented to the hospital due to worsening orthopnea and lower extremity edema. The morning after hospitalization she further deteriorated into SCAI C cardiogenic shock requiring inotropic (dobutamine) and diuretic (furosemide) infusion. An echocardiogram revealed severe biventricular failure and most notably a mural left ventricular thrombus and left atrial appendage thrombus which also extended into the left atrium.

On day 2, she developed acute chest pain and ECG revealed anterior ST elevation consistent with acute myocardial infarction. She was emergently taken to the cardiac catheterization lab where she was found to have thrombus completely occluding the left anterior descending (LAD) as well as involvement in the diagonal and obtuse marginal branches. She required aspiration thrombectomy and multiple inflations to be LAD. Due to her small caliber vessels and diffuse thrombus burden, an intra-aortic balloon pump (IABP) was placed and she was further maintained on heparin infusion and glycoprotein inhibitor.

After cardiac catheterization, her hospital course was relatively uncomplicated. She was able to be weaned off of inotropic support and the IABP was removed 2 days after its placement. She was started on guideline directed medical therapy and discharged on warfarin for anticoagulation.

Discussion

With the emergence of phenotyping for cardiogenic shock, we present a case initially of chronic heart failure shock complicated by acute myocardial infarction secondary to intracardiac thrombus burden. Her shock was managed with combination diuretics, inotropic and intra-aortic balloon pump. Despite hypercoagulable work up 2 years prior, she failed a trial of Eliquis, so she was discharged on a combination of Warfarin with Clopidogrel given her STEMI while inpatient.