Case 5/2015 - 88-Year-Old Female with Chronic Coronary Artery Disease, Upper Limb Thrombosis, Atrial Fibrillation and Cardiac Arrest.

Abstract

An 88-year-old female was admitted due to pain and swelling of the left upper limb swelling (September 28, 2011). She was first admitted to Instituto do Coracao (InCor) at the age of 73 years (December 12, 1996), because of chest angina on great exertion for 8 months. On that occasion, she reported arterial hypertension, glucose intolerance, hypercholesterolemia, hypertriglyceridemia, family history of sudden death, and smoking cessation at the age of 51 years. Her physical examination evidenced heart rate of 60 bpm, blood pressure of 150/80 mmHg. Her heart, lung and abdomen examinations were normal. Her lower limbs showed no edema and her pulses were symmetrical. The electrocardiogram (December 9, 1996) revealed sinus rhythm, an electrically inactive area in the inferodorsal wall, and ventricular repolarization changes with inverted T waves from V1 to V5 (Figure 1). Figure 1 ECG. Sinus rhythm, probable electrically inactive inferodorsal area and diffuse ventricular repolarization changes. The laboratory tests (January 13, 1997) evidenced: glycemia, 115 mg/dL; creatinine, 1.4 mg/dL; total cholesterol, 295 mg/dL; high-density lipoprotein (HDL-cholesterol), 56 mg/dL; low-density lipoprotein (LDL-cholesterol), 183 mg/dL; and triglycerides, 179 mg/dL. Her coronary angiography (December 12, 1996) showed obstructions of 90% in the right coronary and circumflex arteries, and of 70% in the anterior interventricular artery, in addition to normal left ventricular motility. On January 20, 1997, the patient was submitted to successful coronary angioplasty with stent implantation in the circumflex artery, and unsuccessful coronary angioplasty of the right coronary artery, which was occluded. On January 29, 1997, she underwent coronary angioplasty with stent implantation in the anterior interventricular coronary branch. The patient became asymptomatic. On August 8, 1997, control coronary angiography evidenced occlusion of the right coronary artery, irregularities in the interventricular and circumflex arteries, and a 70% obstruction in the first branch of the left marginal artery. The laboratory assessment (March 25, 1998) showed: triglycerides, 338 mg/dL; total cholesterol, 294 mg/dL; LDL-cholesterol, 181 mg/dL; and HDL-cholesterol, 45 mg/dL. On January 27, 2000, a new laboratory assessment evidenced: triglycerides, 166 mg/dL; total cholesterol, 289 mg/dL; LDL-cholesterol, 210 mg/dL; and HDL-cholesterol, 46 mg/dL. Simvastatin was added to the ongoing fenofibrate. The laboratory assessment (December 14, 2001) revealed: triglycerides, 239 mg/dL; total cholesterol, 268 mg/dL; LDL-cholesterol, 160 mg/dL; and HDL-cholesterol, 60 mg/dL. The new coronary angiography (December 18, 2001) showed a 90% obstruction in the right coronary artery, and complicated with injury and thrombosis of the right brachial artery. Thromboembolectomy and brachial-brachial graft with the ipsilateral basilic vein were performed. The patient remained asymptomatic until 2011, with the diagnosis of diabetes mellitus since 2008, when metformin and glybenclamide were prescribed. On August 2011, the patient sought medical care complaining of angina on moderate exertion, being then submitted to coronary angiography (August 22, 2011), which showed: in-stent restenosis of 90% associated with an 80% obstruction in the mid third of the anterior interventricular artery; an 80% obstruction in the first branch of the diagonal artery; a 90% distal obstruction of the circumflex artery with patent coronary stent; an obstruction in the ostium of the second branch of the left marginal artery; a 90% obstruction of the right coronary artery; and preserved left ventricular motility. On September 15, 2011, the patient had prolonged chest pain at rest, and her laboratory assessment showed: hemoglobin, 12.1 g/dL; red blood cell count, 37%; platelets, 348,000/mm3; creatinine, 1.11 mg/dL; potassium, 4 mEq/L; sodium, 140 mEq/L; triglycerides, 223 mg/dL; total cholesterol, 175 mg/dL; HDL-cholesterol, 47 mg/dL; LDL-cholesterol, 83 mg/dL; creatine kinase MB mass, 0.2 ng/mL; troponin, 0.064 ng/mL; activated prothrombin time (APT) according to International Normalized Ratio (INR), 1; and activated partial thromboplastin time ratio (APTT), 0.84. The electrocardiography performed on September 15, 2011, revealed sinus rhythm, diffuse ventricular repolarization changes, and no changes of the special leads V3r, V4r, V7 and V8 (Figures 2 and ​and33). Figure 2 ECG. Sinus rhythm, diffuse ventricular repolarization changes. Figure 3 ECG. Right and dorsal leads, no evidence of ST-segment changes. The sequential laboratory assessment on September 16, 2011, showed creatine kinase MB mass of 0.18 ng/mL and troponin of 0.34 ng/mL. On that same day, the patient underwent balloon angioplasty of the first diagonal branch, with stenting of the anterior interventricular artery. Bleeding, hemoglobin drop to 8.8 g/dL and pseudoaneurysm formation at the left femoral artery puncture site occurred. On September 20 and 23, 2011, the pseudoaneurysm was injected with prothrombin, with resolution of local bleeding. The patient was discharged on September 26, 2011. Two days after hospital discharge, she patient sought the emergency unit because of pain and left upper limb swelling. The laboratory tests on September 28, 2011, showed: hemoglobin, 10.4 g/dL; red blood cell count, 32%; medium corpuscular volume (MCV), 103 fl; leukocytes, 102,310/mm3 (band neutrophils 36%, segmented neutrophils 62%, lymphocytes 1%, monocytes 1%); platelets, 292,000/mm3; creatine kinase MB mass, 0.27 ng/mL; troponin I, 0.126 ng/mL; creatinine, 2.52 mg/dL (glomerular filtration, 19 mL/min/1.73 m2); aspartate aminotransferase (AST), 77 U/L; alanine aminotransferase (ALT), 75 U/L; gamma glutamyl transferase, 179 U/L; total bilirubin, 1.05 mg/dL; direct bilirubin, 0.55 mg/dL; sodium, 136 mEq/L; potassium, 4.6 mEq/L; APT (INR), 1.3; and APTT, 1.04. Doppler ultrasound showed venous thromboses in the left upper limb, and anticoagulant therapy was initiated. A few hours later, the patient had atrial fibrillation with rapid ventricular response. After amiodarone infusion, she had dyspnea, consciousness lowering, respiratory failure requiring orotracheal intubation for ventilatory support, and cardiac arrest with pulseless electrical activity. She recovered, but showed high-grade atrioventricular block, atrial fibrillation, severe bradycardia and right QRS axis deviation. On September 29, 2011, the laboratory tests were as follows: hemoglobin, 10.5 g/dL; red blood cell count, 35%; MCV, 109 fl; leukocytes, 9,820/mm3 (metamyelocytes 1%, band neutrophils 40%, segmented neutrophils 41%, eosinophils 1%, lymphocytes 14%, monocytes 3%); platelets, 202,000/mm3; creatine kinase MB mass, 13.19 ng/mL; troponin I, 1.22 ng/mL; urea, 108 mg/dL; creatinine, 2.82 mg/dL (glomerular filtration, 12 mL/min/1.73m2); sodium, 135 mEq/L; potassium, 5 mEq/L; AST, 756 U/L; ALT, 312 U/L; gamma glutamyl transferase, 136 U/L; total bilirubin, 1.19 mg/dL; direct bilirubin, 0.71 mg/dL; C-reactive protein, 209 mg/L; venous lactate, 105 mg/dL; APT (INR), 3.9; and APTT, 7.97. Venous blood gas analysis showed: pH, 6.55; pCO2, 33.9 mm Hg; pO2, 27.1 mm Hg; O2 saturation, 21.4%; bicarbonate, 2.8 mEq/L; and base excess, (-) 29.8 mEq/L. The patient underwent temporary pacemaker implantation, but the refractory shock persisted. She had a new cardiac arrest and no longer responded to resuscitation maneuvers, dying on September 29, 2011.