Exploring complex cardiac cases: Insights from diverse presentations in mid-aged women

R.Vinoth1, N. Dharsshini2

Clinical Pharmacist and Quality Executive, Kauvery Hospital

Clinical Pharmacist, Kauvery Hospital

Case presentation

Case – 1

A 26-year-aged female with a history of Post-COVID status in 2021 presented with a four-day history of fever, bilateral shoulder pain for two days, vomiting, and giddiness. She had been evaluated and treated at another hospital before being referred for further management.

Upon examination, the patient was conscious but tachypneic, tachycardic, and hypotensive. Her ECG showed ST elevation in lead II, III, AVF, V5-V6, and an ECHO revealed global hypokinesia with severe left ventricular dysfunction. Cardiac enzymes (Trop T) were positive, leading to a diagnosis of Myopericarditis, severe left ventricular dysfunction, acute pulmonary edema, and refractory cardiogenic shock.

Treatment was initiated with inotropes for hypotension, intravenous anticoagulants, and antiplatelets. Despite these measures, the patient remained persistently hypotensive, prompting the decision to consider IABP/ECMO support. During the course of management, the patient suddenly became unresponsive, necessitating emergency intubation. Subsequently, she developed bradycardia, leading to initiation of cardiopulmonary resuscitation (CPR) following ACLS protocol. Unfortunately, the patient went into ventricular fibrillation (VF), and despite the delivery of a 150J DC shock, resuscitation efforts were unsuccessful, and the patient was declared deceased.

Case – 2

A 35-year-aged female presented with a history of fever, chills, rigor, bilateral shoulder, and arm pain, along with giddiness. She had received prior treatment in another hospital, where she developed sudden onset breathlessness and right shoulder pain, necessitating referral for further management. The patient had engaged in increased physical exertion and participated in athletic events. Upon arrival, the patient was conscious, oriented, but dyspneic, tachypneic, hypotensive, and tachycardic. ECG revealed sinus rhythm with qRBBB, ST elevation in V1-V2, T inversion in V4-V6, and ST depression in II, III, and AVF. ECHO demonstrated global asymmetric hypertrophy with left ventricular dysfunction. Coronary angiography (CAG) showed normal coronaries.

Lab investigations indicated an elevated total count, increased C-reactive protein (CRP), and ABG analysis revealed severe metabolic acidosis with elevated lactate levels. A provisional diagnosis was made, including Sepsis with Septic Shock, Myocarditis with Left Ventricular Dysfunction, Hypertrophic Cardiomyopathy (HCM), and Athlete’s Heart.

Treatment was initiated, incorporating intravenous inotropes, antibiotics, anticoagulants, and NIV support. Despite initial stabilization, the patient’s condition deteriorated, leading to intubation. Subsequently, the patient became unconscious and unresponsive, experiencing ventricular tachycardia (VT) that reverted with a 150J DC shock. Following this, sudden bradycardia ensued, prompting immediate initiation of cardiopulmonary resuscitation (CPR) according to ACLS protocol. Unfortunately, despite exhaustive resuscitative efforts, the patient could not be revived, and she was declared deceased.

Case – 3

A 39 years old female with hypertensin, diabetes had a history fever for last five days, was diagnosed to have dengue at an outside hospital and started on IV antibiotics three days earlier.

Patient had chest discomfort associated with breathlessness. ECG showed significant ST changes. Hence, patient referred for further evaluation and management. ECHO revealed severe LV dysfunction and regional wall motion abnormalities (RWMA) in the LAD territory.

Patient was conscious, oriented and afebrile. At the time of admission her platelet count was 74000 (rechecked) cells/ Cu mm, with increase in platelet count on further days, Dengue serology was negative, Troponin level was 8.06 ng/mL.

Patient was diagnosed with SHT, Type2 DM, CAD, recent high lateral wall MI-not lysed-, moderate LV dysfunction, and Dengue with thrombocytopenia.

Initially started with Aminophylline infusion and Inj Nexium infusion, other cardio protective drugs and 3% NaCl in view of hyponatremia. Patient became clinically better, had good urine output and was afebrile. Treatment continued for two more days; platelet count had an increasing trend hence planned for CAG. After prior preparation. CAG was done on 1/12/2023, which showed normal coronaries. Post procedure was uneventful. Patient was treated with IV fluids, IV antibiotics, anticoagulants, Beta Blockers, H2 receptors, anticoagulants, Statins, antiplatelet, antiemetic and other cardiac supportive drugs. Patient general condition improved and hence discharged.

Case – 4 

A 52 years old female came with complaint of chest pain, nine episodes of vomiting and breathing discomfort since previous night. She had a history of fever with thrombocytopenia, with one episode of melena and was treated the previous week with four units of Platelets. She had received a loading dose, given outside, for possible ACS. Not known to have DM/ HTN/BA.

On examination patient was conscious, oriented, and afebrile. At the time of admission her platelet count was 411000 Cells/Cu mm, WBC count was elevated and Dengue serology was negative.

Patient was planned for CAG. CAG was done which showed SVD, she was diagnosed with Coronary Artery Disease, Acute Inferior-Lateral Wall MI, with normal LV Function. Successful PTCA with stenting was done to LAD. Post procedure period was uneventful. Patient was treated with antibiotics, anticoagulants, antiplatelet, H2 receptors blockers, Beta blockers, statins, antianginal and other cardiac supportive drugs. Patient’s condition improved and hence discharged.

Discussion

The case report presents a diverse spectrum of cardiac pathologies in mid-aged female patients, each with different challenges and outcomes. All the patients presented with different cardiac conditions; despite aggressive resuscitative measures two patients could not be revived. These cases highlight the broad spectrum of cardiac presentations, ranging from infectious etiologies to acute coronary syndromes.

Case1

The above figure represents the common etiological patterns of coronary heart disease. There are some common and uncommon pathological process for myocardial infarct. In the case summaries which is discussed above, factors like SARS covid, Diabetes, Hypertension, rigorous physical activity etc can be contributing risk factors for developing abnormal coronaries. These different cases and etiology can be a learning opportunity to think of the possibility for coronary heart disease.

Conclusion

These cases serve as valuable learning experiences for healthcare professionals in understanding and navigating the complexities of cardiac pathology. The complexity of these cases underscores the importance of accurate diagnosis, considering the potential overlap of multiple cardiac conditions. Despite advances in medical care, the fatal outcomes in some patients underscore the challenges and limitations in managing severe cardiac pathologies, necessitating ongoing research innovation.

Case2

Vinoth Rajendran

Clinical Pharmacist-CST

Case3

N. Dharsshini

Clinical Pharmacist

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