Myocardial infarction with ventricular septal rupture and cardiogenic shock D. Luke Glancy, MD, Bahij N. Khuri, MD, Jihad A. Mustapha, MD, Pramod V. Menon, MD, and Elias B. Hanna, MD
Figure. Electrocardiogram recorded on the patient’s arrival in the emergency department. See text for explication. Also, note that there was sinus rhythm at a rate of 106 beats/min with the next to last QRS complex being a fusion of a premature ventricular complex with a sinus-initiated complex.
A
72-year-old woman with a history of systemic arterial hypertension presented to the emergency department with chest pain, and an electrocardiogram showed acute anterior myocardial infarction with striking ST-segment elevation, upright T waves, and large Q waves in leads V1 to V4 (Figure). Furthermore, the ST-segment elevation > 0.25 mV in lead V1, the ST depression ≥ 0.1 mV in lead III, and the ST elevation ≥ 0.1 mV in lead aVL indicated that the left anterior descending coronary artery was occluded proximal to both the first major septal perforating branch and the first diagonal branch (1–4). Anterior infarcts from such proximal left anterior descending occlusions tend to be quite large and are often associated with cardiogenic shock (2, 4, 5), which this woman manifested soon after her arrival in the emergency department. An echo512
cardiogram showed a left ventricular ejection fraction of approximately 40% with akinesis of the apex and distal two-thirds of the ventricular septum. The right ventricle was considerably dilated. Through a defect in the distal ventricular septum, blood shunted from left to right during systole with reversal of flow during diastole, suggesting an elevated right ventricular diastolic pressure. Laboratory studies of the patient’s blood confirmed From the Sections of Cardiology, Departments of Medicine, Louisiana State University Health Sciences Center and the Interim LSU Hospital, New Orleans, Louisiana. Currently, Dr. Khuri practices at the Ochsner Hospital in Baton Rouge; Dr. Mustapha practices in Michigan; and Dr. Menon practices in Covington, Louisiana. Corresponding author: D. Luke Glancy, MD, 1203 West Cherry Hill Loop, Folsom, LA 70437 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2015;28(4):512–513
Table. Laboratory results from blood drawn on admission Test
Flag
Value Reference range
CBC White blood cell count (103/μL) Red blood cell count
(106/μL)
High Low
22.1 3.43
4.5–11.0 4.0–5.2
Hemoglobin (g/dL)
Low
10.4
12.0–16.0
Hematocrit (%)
Low
31.4
35–46
Mean corpuscular volume (fL)
91.4
80–100
Mean corpuscular hemoglobin (pg)
30.2
26–34
Absolute neutrophil count– segmented (103/μL)
High
17.02
1.8–8.0
Absolute neutrophil count–bands (103/μL)
High
2.65
0–0.9
Basic metabolic profile Sodium (mmol/L) Potassium (mmol/L) Chloride (mmol/L)
145
135–146
3.8
3.6–5.2
98
96–107
CO2 (mmol/L)
Low
11
24–32
Glucose (mg/dL)
High
275
65–109
Blood urea nitrogen (mg/dL)
18
7–25
Creatinine (mg/dL)
High
2.9
0.7–1.2
Calcium (mg/dL)
Low
6.4
8.4–10.3
Magnesium (mg/dL)
High
3.6
1.5–2.6
Phosphorous (mg/dL)
High
10.6
2.5–4.7
Creatine kinase (U/L)
High
710
Figure. Electrocardiogram recorded on the patient’s arrival in the emergency department. See text for explication. Also, note that there was sinus rhythm at a rate of 106 beats/min with the next to last QRS complex being a fusion of a premature ventricular complex with a sinus-initiated complex.
A
72-year-old woman with a history of systemic arterial hypertension presented to the emergency department with chest pain, and an electrocardiogram showed acute anterior myocardial infarction with striking ST-segment elevation, upright T waves, and large Q waves in leads V1 to V4 (Figure). Furthermore, the ST-segment elevation > 0.25 mV in lead V1, the ST depression ≥ 0.1 mV in lead III, and the ST elevation ≥ 0.1 mV in lead aVL indicated that the left anterior descending coronary artery was occluded proximal to both the first major septal perforating branch and the first diagonal branch (1–4). Anterior infarcts from such proximal left anterior descending occlusions tend to be quite large and are often associated with cardiogenic shock (2, 4, 5), which this woman manifested soon after her arrival in the emergency department. An echo512
cardiogram showed a left ventricular ejection fraction of approximately 40% with akinesis of the apex and distal two-thirds of the ventricular septum. The right ventricle was considerably dilated. Through a defect in the distal ventricular septum, blood shunted from left to right during systole with reversal of flow during diastole, suggesting an elevated right ventricular diastolic pressure. Laboratory studies of the patient’s blood confirmed From the Sections of Cardiology, Departments of Medicine, Louisiana State University Health Sciences Center and the Interim LSU Hospital, New Orleans, Louisiana. Currently, Dr. Khuri practices at the Ochsner Hospital in Baton Rouge; Dr. Mustapha practices in Michigan; and Dr. Menon practices in Covington, Louisiana. Corresponding author: D. Luke Glancy, MD, 1203 West Cherry Hill Loop, Folsom, LA 70437 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2015;28(4):512–513
Table. Laboratory results from blood drawn on admission Test
Flag
Value Reference range
CBC White blood cell count (103/μL) Red blood cell count
(106/μL)
High Low
22.1 3.43
4.5–11.0 4.0–5.2
Hemoglobin (g/dL)
Low
10.4
12.0–16.0
Hematocrit (%)
Low
31.4
35–46
Mean corpuscular volume (fL)
91.4
80–100
Mean corpuscular hemoglobin (pg)
30.2
26–34
Absolute neutrophil count– segmented (103/μL)
High
17.02
1.8–8.0
Absolute neutrophil count–bands (103/μL)
High
2.65
0–0.9
Basic metabolic profile Sodium (mmol/L) Potassium (mmol/L) Chloride (mmol/L)
145
135–146
3.8
3.6–5.2
98
96–107
CO2 (mmol/L)
Low
11
24–32
Glucose (mg/dL)
High
275
65–109
Blood urea nitrogen (mg/dL)
18
7–25
Creatinine (mg/dL)
High
2.9
0.7–1.2
Calcium (mg/dL)
Low
6.4
8.4–10.3
Magnesium (mg/dL)
High
3.6
1.5–2.6
Phosphorous (mg/dL)
High
10.6
2.5–4.7
Creatine kinase (U/L)
High
710
![[Myocardial infarction and cardiogenic shock].](/assets/img/hold.png)
