Case 6-Late Cardiogenic Shock after Myocardial Infarction in a 50 Year-Old Hypertensive and Diabetic Man

Abstract

A 50-year-old Caucasian male patient, a coppersmith by profession, born in Recife (State of Pernambuco) and living in Sao Paulo (SP), with a history of previous myocardial infarction, hypertension, diabetes and chronic renal failure was hospitalized with hypotension and decompensated heart failure. At 42 years of age (year 2000), he presented with prolonged chest pain and was hospitalized with the diagnosis of acute myocardial infarction. Cineangiography at that time revealed a 50% lesion in the anterior interventricular branch, a 90% lesion in the circumflex branch which appeared to be recanalized, and occlusion of the right coronary artery. Ventriculography revealed inferolaterobasal akinesia. Echocardiography (February 2000) showed a left atrium with 51 mm, left ventricle with 62 mm, left ventricular ejection fraction of 41% (Teichholz), inferior and lateral wall akinesia, and moderate mitral regurgitation (Table 1). After this episode, he developed dyspnea on exertion, which progressed to dyspnea at rest and orthopnea, accompanied by leg edema. Approximately two years after the infarction, he was hospitalized for right lobar pneumonia and empyema, which was drained (December 2001). The patient was then referred to InCor for treatment of heart failure. He also had hypertension and type II diabetes mellitus, and had been a smoker up until the time of infarction. He was on glibenclamide 10 mg, isosorbide mononitrate 80 mg, spironolactone 100 mg, digoxin 0.25 mg, furosemide 120 mg, captopril 100 mg, and ASA 100 mg daily. Physical examination (01/18/2002) revealed an emaciated patient, with a heart rate of 104 beats per minute, blood pressure of 120/86 mmHg, grade 3/4 jugular venous distension; pulses were normal and symmetrical to palpation;