ABC | Volume 110, Nº4, April 2018

Anatomopathological Correlation Case 2/2018 - 73-Year-Old Male with Ischemic Cardiomyopathy, Cachexia and Shock Rafael Amorim Belo Nunes, Jussara de Almeida Bruno, Hilda Sara Monteiro Ramirez, Léa Maria Macruz Ferreira Demarchi Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP - Brazil Mailing Address:Vera Demarchi Aiello • Avenida Dr. Enéas de Carvalho Aguiar, 44, subsolo, bloco I, Cerqueira César. Postal Code 05403-000, São Paulo, SP – Brazil E-mail: demarchi@cardiol.br , vera.aiello@incor.usp.br Keywords Atherosclerosis; Heart Failure/physiopathology; Cardiomyopathy, Dilated/complications; Weight Loss; Cachexia Section editor: Alfredo José Mansur (ajmansur@incor.usp.br ) Associated editors: Desidério Favarato (dclfavarato@incor.usp.br ) Vera Demarchi Aiello (vera.aiello@incor.usp.br ) DOI: 10.5935/abc.20180065 The patient is a 73-year-old male, born in the municipality of Jacupiranga, SP, and coming from São Paulo city, SP, complaining of 30-kg weight loss in the previous 4 months and worsening of his general state of health in the previous 24 hours. He reported having coronary artery disease, with two episodes of infarction and one coronary angioplasty with stent implantation 8 years before. He had been diagnosed with ischemic cardiomyopathy and ejection fraction of 22%. He was using spironolactone, losartan, carvedilol, furosemide and propatylnitrate. His physical examination (April 29, 2004) showed emaciation, dehydration, heart rate of 80 bpm, inaudible blood pressure, increased jugular venous pressure, lungs with inspiratory wheezes, regular heart rhythm and no heart murmur on cardiac auscultation, liver palpable 3 cm from the right costal margin, and mild edema of the lower limbs. The patient received 1500 mL of 0.9% saline solution, which increased his blood pressure to 90/70 mm Hg. The results of his laboratory tests (April 30, 2004) were as follows: hemoglobin, 17.2 g/dL; platelets, 99000/mm³; leukocytes, 7850/mm³; urea, 122mg/dL; creatinine, 2.2mg/dL; potassium, 6.5 mEq/L; sodium, 143 mE/L. His arterial blood gas analysis was as follows: pH, 7.3; bicarbonate, 16 mEq/L; and base excess, (-)7 mEq/L. His electrocardiogram (April 29, 2004) (Figure 1) showed sinus rhythm, heart rate of 68 bpm, PR of 200 ms, dQRS of 120 ms, QT of 440 ms, left atrial overload and indirect signs of right overload (Peñaloza-Tranchesi), in addition to left anterior hemiblock. No pathological Q wave was seen. He was admitted to the Hospital Auxiliar de Cotoxó to compensate his heart failure and acute renal failure. The patient progressed with oliguria, dyspnea, and, on the third day of admission, he had sudden lowering of consciousness, fever and respiratory failure, requiring endotracheal intubation. His previous laboratory tests on that same day were as follows: hemoglobin, 14.5 g/dL; leukocytes, 8500/mm³; sodium, 139 mEq/L; potassium, 3.7 mEq/L; urea, 170 mg/dL; creatinine, 2.2 mg/dL; leukocyturia, 10000/mL; and hematuria, 280000/mL. During that episode, the findings were as follows: heart rate, 75 bpm; blood pressure, 100/60 mmHg; temperature, 37.8°C; arterial saturation, 97%; and crepitant rales at pulmonary bases. His heart rhythm was regular, with neither murmur nor accessory heart sound. His capillary glycemia was 166 mg/dL. The patient was referred to the emergency unit of Incor. Pulmonary aspiration and stroke were his clinical suspicions. His physical examination on admission (April 3, 2004) revealed an agitated and intubated patient, with heart rate of 90 bpm, blood pressure of 68/49 mm Hg, respiratory rate of 36 bpm, lungs with diffuse rhonchi, no abnormality on cardiac auscultation. His liver was palpated 3 cm from the right costal margin. There was edema (+++) of the lower limbs, with no signs of calf swelling. Sedationwas prescribed, as were dobutamine, noradrenaline, enoxaparin, vancomycin and imipenem/cilastatin. His cranial tomography (May 4, 2004) showed a right occipital low attenuation area, widening of the cortical sulci, and no other significant change, findings compatible with right occipital ischemic stroke. The patient remained shocked despite the administration of vasoactive amines, had bradycardia and asystole, and died (May 5, 2004; 16 h). Clinical aspects The patient here reported is a male elderly with ischemic cardiomyopathy, and significant weight loss in the previous 4 months, in addition to worsening of his general state of health and clinical instability in the 24 hours prior to admission. Some diagnostic possibilities could explain his significant weight loss. Cardiac cachexia is a frequent complication in the advanced stages of congestive heart failure (CHF) and associates with shorter survival. 1 The physiopathology of that disorder has been first described by Pitman and Cohen 2 Later, new evidence showed that the cause is multifactorial, related mainly to anorexia, a change in the routine of food uptake, in absorption and in the metabolism of patients with heart 388