The silent hunter waiting for its prey: refractory cardiogenic shock in a young diabetic woman with debatable late invasive approach

Introduction: Cardiogenic shock is a life-threatening complication after a myocardial infarction, with high mortality, in which aggressive interventional approach should be recommended. Case report: A 58 year old woman was admitted for recurrent chest pain at rest and acute pulmonary edema. She was hypertensive, former smoker, diabetic (on insulin), with a history of inferior MI treated by primary PCI with 2 BMS in the mid-distal RCA, and subsequent elective PCI with a BMS in the mid-LCX and a DES in the proximal LAD. She was symptom-free for 2 years until 2 weeks prior to this admission, when she started to develop resting angina. Methods: At admission, BP was 100/60 mm Hg, HR 102 bpm, while ECG showed old Q waves in the inferior leads, and new Q waves from V1 to V4. Troponin I (5 ng/ml) and NT pro-BNP (12,000 pg/ml) were increased. Echocardiography showed EF of 15%, moderate mitral regurgitation, and restrictive diastolic profile. One hour after, she developed cardiogenic shock. Emergency coronary angiography was considered, however, not performed due to late presentation aft er MI and low expected benefit vs. procedural risk. Patient remained in cardiogenic shock despite aggressive medical treatment for 2 weeks, when she developed severe systemic congestion which ameliorated slowly aft er another 6 weeks. NT pro-BNP dropped to 4,000 pg/ml. Results: Since the patient was now stable on maximal medication, coronary angiography was eventually performed. It showed a “de-novo” critical stenosis in the proximal LAD, proximal to the previous stent, without other lesions. PCI was performed, while patient developed acute heart failure during the procedure, which responded to standard treatment (i.v. dobutamine and loop diuretic). She was discharged after 10 weeks of hospital admission, on DAPT, digoxin, aldosterone antagonist, loop diuretic, beta-blocker, ACE inhibitor, statin, and insulin therapy. Follow-up at 1 and 3 months was uneventful, without angina, and in NYHA class II; echo showed EF of 30%, mild LV dilatation (EDD of 59 mm), moderate mitral regurgitation, and pseudo normal diastolic profile. She was kept on the same medication. Conclusion: We present a case of severe cardiogenic shock in a diabetic patient with multiple co-morbidities, which resolved after PCI of a “de-novo” proximal LAD lesion. Implications: Despite critical condition, emergency coronary angiography should not be postponed, mainly in diabetic patients with multiple revascularization procedures, since treatable lesions might be revealed.

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