MI and Cardiogenic Shock
Patient Presentation:
K.M., a 73-year-old male, presented to the ED with a primary complaint of chest pain. K.M. has past medical history of Type 2 Diabetes, hypertension, hyperlipidemia, stroke, dementia, complete heart block with permanent pacemaker placement, and bladder cancer. Upon admission to the ED, K.M. was alert but confused, and complained of severe pain/heaviness to his chest. Patient was diaphoretic and short of breath. In the ED, 2 large bore IV’s were started and supplemental oxygen was administered via nasal cannula.
Differential Diagnoses:
Considering the patient’s history, the most likely diagnosis is acute myocardial infarction.
Diagnosis:
EKG revealed ST segment elevation. Cardiac enzymes were elevated, and serial cardiac enzymes that were drawn demonstrated a peak in Troponin at 34.7. K.M. was taken for an emergent cardiac catheterization, which revealed the patient was experiencing an acute myocardial infarction, with multiple vessel injury and an ejection fraction of 25-30%.
Treatment:
K.M. was taken to the operating room for Coronary Artery Bypass Graft (CABG). The left internal mammary artery was used to bypass the left anterior descending artery, and the saphenous vein graft was used to bypass the posterior descending artery. Postoperatively in the ICU, the patient had severe agitation with cardiac insufficiency, as evidenced by hypotension, tachycardia, and cardiac index < 1.8 (L/min/m2) as determined per the pulmonary artery catheter. The patient was also oliguric and had cool, clammy skin. K.M. was diagnosed with cardiogenic shock. The patient remained intubated, was put on a dexmedetomidine drip for sedation, and was started on a milrinone drip for positive inotropic effects. K.M. was also started on a vasopressin drip and a norepinephrine drip due to vasodilation and hypotension. Norepinephrine was titrated for a goal mean arterial pressure of 65-95 mmHg. A Lasix® drip was started due to fluid retention and fluid overload. On inotropes and pressors, patient maintained a goal cardiac index of greater than 2.4. Pulmonary artery pressures were elevated in 30-40s/20s mmHg (normal ~ 25/10). K.M. was started on sildenafil (Viagra®) to treat his pulmonary hypertension.
Outcome:
Over the next few days, K.M. was weaned off sedation and was extubated. Milrinone, vasopressin, and norepinephrine were slowly weaned off over the next week, and the patient was able to maintain adequate cardiac output values (>4) and adequate cardiac index values (>2.5). K.M. was transferred from the ICU to a cardiac floor for further recovery.