ABC | Volume 111, Nº6, December 2018

Anatomopathological Correlation Case 6 – Woman with Ischemic Heart Disease Admitted due to Chest Pain and Shock Rafael Amorim Belo Nunes, Hilda Sara Montero Ramirez, Vera Demarchi Aiello Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-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 , anpvera@incor.usp.br Manuscript received October 04, 2018, revised manuscript October 05, 2018, accepted October 09, 2018 Keywords Myocardial Ischemia; Myocardial Infarction; Chest Pain; Cardiac Catheterization;Thromboembolism; Shock, Cardiogenic Section Editor: Alfredo José Mansur (ajmansur@incor.usp.br ) Associated Editors: Desidério Favarato (dclfavarato@incor.usp.br ) Vera Demarchi Aiello (anpvera@incor.usp.br ) DOI: 10.5935/abc.20180231 A 67-year-old woman sought emergency medical care due to prolonged chest pain. In April 2009 the patient had prolonged chest pain and at that time she sought medical care. She was admitted at the hospital and diagnosed with myocardial infarction. The patient had hypertension, diabetes mellitus, dyslipidemia and was a smoker. During the patient’s evolution, after the myocardial infarction, she was submitted to a coronary angiography in, which disclosed the presence of lesions with 70% obstruction in the right coronary, anterior descending and circumflex arteries. A left ventriculography revealed apical akinesia with signs of intracavitary thrombus in that region. The echocardiogram (May 2009) disclosed ventricular dysfunction accentuated by diffuse hypokinesis, with a 28% left ventricular ejection fraction. Clinical and drug treatment was recommended to the patient. The patient’s evolutionwas asymptomatic until October 2009, when she had a cerebrovascular accident, with motor sequela. On December 30, 2009, the patient had an episode of severe chest pain that lasted for one hour and she sought medical care. At the physical examination, the heart rate (HR) was 100 beats per minute, blood pressure was 100/60 mmHg. Pulmonary assessment was normal. The heart examination disclosed a ++/ 6+ systolic murmur in the mitral area. The remainder of the physical examination was normal. The electrocardiogram (1h 19min; Dec 30, 2009) showed sinus rhythm, HR of 103 bpm, PR interval of 122 ms, QRS duration of 159 ms, QT interval of 367 ms, and corrected QT of 480 ms. Therewas left atrial overload, low voltage of theQRS complex in the frontal plane, probable inferior electrically inactive area, and left bundle branch block (Figure 1). Chest x-ray disclosed the presence of a large pleural effusion in the right hemithorax. The laboratory tests showed hemoglobin 13 g/dL, hematocrit 40%, MCV 91 fL, leukocytes 12,400/mm³ (66% neutrophils, 1% eosinophils, 1% basophils, 19% lymphocytes and 13% monocytes), 421,000/mm³, total cholesterol 228 mg/dL, HDL‑cholesterol 35 mg / dL, LDL-cholesterol 162 mg/dL, triglycerides 157 mg/dL, CK-MB mass 5.63 ng / mL, Troponin I 0.21 ng/mL, urea 33 mg/dL, creatinine 0.66 mg/dL, sodium 137 mEq/L, and potassium 3.4 mEq/L. Venous blood gasometry showed pH 7.46, pCO 2 39.3 mmHg, pO 2 36.3 mmHg, O 2 saturation 62.7%, bicarbonate 27.7 mEq/L and base excess 4.1 mEq/L. Approximately two hours after hospital admission, she had seizures and cardiac arrest with pulseless electrical activity, reversed in 5 min. The electrocardiogram after the cardiac arrest (4:18 am; Dec 30, 2009) showed a HR of 64 bpm, absence of P waves, and left bundle branch block. The QRS complex alteration, in relation to the previous tracing, was a positive QRS complex in the V6 lead (Figure 2). She had a new cardiac arrest 20 min later, which was also reversed. After half an hour, a new episode of cardiac arrest occurred, which was irreversible, and the patient died (5:45 am; Dec 30, 2009). Clinical aspects This patient is a 67-year-old woman with cardiovascular risk factors and ischemic cardiomyopathy, with severe left ventricular systolic dysfunction. Cardiac catheterization disclosedmultivessel coronary disease and apical akinesis with an intracavitary thrombus. During outpatient follow-up, clinical treatment was chosen, possibly influenced by the patient’s clinical status, as well as the characteristics of the coronary anatomy. The indication of surgical treatment with myocardial revascularization in patients with coronary heart disease with heart failure and severe left ventricular systolic dysfunction is still debatable, but recent data from the STICH study suggest a long-term survival benefit in patients undergoing myocardial revascularization. 1 During follow-up in October 2009, the patient had a clinical picture suggestive of a cerebrovascular accident that may have been of atherothrombotic origin due to the multiple cardiovascular risk factors or of cardioembolic origin, associated with intracavitary thrombi. In December 2009 the patient was admitted to the emergency room with acute chest pain. She had mild tachycardia and borderline systolic blood pressure of 100 mmHg. The electrocardiogram showed sinus tachycardia, left atrial overload and left bundle branch block. In patients with acute chest pain and electrocardiogram with acute or undetermined left bundle branch block, 860