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In-Stent Thrombosis or Acute Heart Failure
?
History
Male, 64yrs
Persistent chest pain 22hrs ,admitted on 1st Mar. 2011,the symptom did not relieve at admission
Old myocardial infarction five years ago, underwent PCI at that time, has not taken any medicine since 3 years ago
Hypertension for 10 years
T2DM for 5 years
gout for 3 years
Physical Examination T:35.8℃, P:74bpm, R:18bpm ,
Bp:133/77mmHg
Slight cyanosis
No distention of jugular vein, no rales, no murmur and no S3
No edema
adjunctive Examination
ECG (3.1) : sinus rhythm with ST of
II 、 III 、 aVF , V7-V9 elevated for 0.1-0.2mV
Cardiac marker: CKMB mass >80ng/ml
Myo >500ng/ml
cTNI >30ng/ml
BNP : 414pg/ml
ECG at admission
Adjunctive test
BUN: 6.93mmol/L, Cr: 70 umol/L
LDH:1272U/L, CK: 3645U/L, CKMB: 349U/L, cTNI: (+)
Na: 134.3mmol/L, K: 4.41 mmol/L
WBC:17.62 *109/L, N: 89.3%,
Hb:157g/L,PLT :273*109/L
BGA: PH:7.49, PaO2:77mmHg, PaCO2:33mmHg,
SaO2:96%
diagnosis
CAHD
acute myocardial infarction (inferior wall)
old myocardial infardtion (anterior wall)
Killip I
Hypertension
T2DM
gout
Therapy ASA + Clopidogrel+Tirofiban to enhence anti-
platelet and anti-coagulation
Statins to stabilize the plaque
ACEI to prevent ventricular remodeling
Primary CAG+PCI
CAG(1)
LMd:50%, LADo:70% in-stent re-stenosis , LADm:70%, D1:70%; LCX:100%
CAG(2)
Small RCA
PCI-1
Wire and thrombus aspiration
PCI-2
After thrombus
aspiration twice
PCI-3
Balloon dilatation
2.0*15mm@8-10atm
PCI-4
Stent deployment :
2.75*29mm Partener @ 10atm
PCI-5
In-stent postdilatation with Durastar 3.0*10mm@10-20atm
PCI-6
Final Results
ECG After PCI
ECG of the next day after PCI
X-Ray (2011.3.1) : increase of lungmarkings
enlargement of heart shadow
UCG : enlargment of left atrial
segmental ventricle hepo-kinetics (AMI of Inferior wall )
LVEF:43%
Mean Pulmonary Artery pressure:47mmHg
X-Ray and UCG
UCG at admission
Acute myocardial infarctin ( inferior wall)
Segmental hypo-kinetics
Left artial enlargement
Systolic dysfunction of LV
LVEF : 43%
Holter Sinus Rhythm
Acute myocardial infarction of inferior wall
HRV:76ms
(2011.3.2): LDH: 1426U/L, CK: 2194U/L
CK-MB: 131U/L, cTNI (+)
(2011.3.3): LDH: 1194U/L, CK:695U/L
CK-MB:40U/L
BUN:7.44mmol/L, Cr:86umol/L
WBC: 8.84*109/L, N:78.6%, Hb:131g/L
Laboratory Test
Continue with anti-platelet 、 anti-
coagulation 、 lipid-lowering 、 inhibit
ventricular remodeling and anti-inflammation
therapy
No chest pain and no dyspnea
Sequential Therapy
But 5 days later…… Breast distress and sweating accompanied with dyspnea
ECG:ST II 、 III 、 avF , V7-V9 elevated for 0.2mV
HR : 102bpm , Bp : 88/59mmHg , SpO2:90% , No moist rales
Treatment : NTG : 0.5mg sublingually, NTG 5ug/min iv
Torasemide : 20mg iv
Cedelaind : 0.4mg iv
Clopidogrel : 300mg Po st
Tirofiban : 17ml iv , 15ml/h
ECG of recurrent dyspnea
cyanosis, sweating, passive sitting position.HR:101bpm,Bp:95/57mmHg
30 minutes later
Symptom worsening
Transfer to CCU 1hr later
Symptom did not relieve after medical treatment
HR:121bpm,Bp:90/45mmHg , SpO2:87-90% , sitting position , moist rales and S3 can be heard, no edema
Non-invasive mechanical ventilation
IABP
Morphine,diuretics, dopamine , dobutamine nitrates
Cardiac marker(6 hrs after recurrent symptom) CKMB mass 5.0ng/ml Myo 302 ng/ml cTNI 9.59 ng/ml BNP 1150 pg/ml
Cardiac marker(18 hrs after recurrent symptom) LDH 708 U/L CK 114 U/L CK-MB 21U/L
Laboratory test(1)
Laboratory test(2) BUN 7.3 mmol/L, Cr 96umol/L
WBC 9.25×109/L, N 85.6%, PLT 354×109 /L, Hb 157g/L
BGA: PH 7.44, PaO2 62mmHg, PaCO2 29mmHg, SaO2 90%
ECG in CCU
UCG in CCU
UCG Acute myocardial infarction (inferior wall)
Segmental ventricular hypo-kinetics
LVEF :42%
Systolic dysfunction
X-Ray
WBC 15.51×109/L, N 94.3%, PLT 336×109 /L, Hb 145g/L
LDH 586U/L, CK 123U/L, CK-MB 17U/L
Na 134.2 mmol/L , K 4.54 mmol/L
BUN 13.9 mmol/L, Cr 124umol/L
BGA: PH 7.40, PaO2 : 57mmHg, PaCO2 : 33mmHg, SaO2 :87%
PCT : 0.5ng/ml
Laboratory test (1 day after recurrent symptom)
Clinical outcome The patient’s condition got aggrevated even
with anti-imflamation , diuretics, inotropic agents 、 vaso-active agents
The symptom exacerbating , SpO2 decreasing to about 80%
Invasive mechanical Ventilation 1 day later
ECG of the next day
X-Ray :inflammation aggravated
出入量
Date 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
Fluid Infusion 1765 915 765 665 660 355 3374 2342
Drink 1260 1200 2090 2100 1900 1650 200 50
Urine 1400 1850 2450 2375 1825 2825 911 1417
Balance +1625 +265 +405 +390 +735 -820 +2663 +975
Laboratory Test of 2011.03.09
WBC : 19×109/L, N : 94%
TNI : 1.97ng/ml CK-MB : 18U/L
BUN : 21 mmol/L, Cr : 143umol/L
BGA: PH : 7.39, PaO2 : 58.8mmHg
PaCO2 : 32mmHg, BE : -4.9 mmol/L ,Lac : 2.5mmol/L
BNP : 1080pg/ml
X-Ray of the third day
Discussion ( 1 ) --- What do you think about this patient?
Recurrent myocardial infarction caused by subacute in-stent thrombus formation ?
Acute heart failure
Both
Discussion ( 2 ) --- What should we do?
Medical therapy? heart failure 、 anti-inflammation 、 anti-ischemia ……
CAG again?
If CAG, the incidence of CIN is very high, and the toxicity of contrast must be taken into consideration
Revascularization ?
If revascularization , IRA only or complete revascularization?
CAG : on the third day of recurrence( 1 )
CAG : on the third day of recurrence ( 3 )
Discussion ( 3 ) The cause of acute heart failure?
No new-onset occlusion of coronary artery
No infectious disease before
The balance of liquid is almost equal
ECG showed ST elevated , but no elevated cardiac marker , is CAG most needed ? How to evaluate?
Is completed revascularization of helpful?
Outcome
The patient’s relatives asked to quit all treatment because of financial causes
Died of heart failure