CASE REPORT
A 42-year-old male patient with a history of type 2 diabetes under the treatment of 2000mg/day of Metformin presented with typical angina chest pain and dyspnea for 3 days before being hospitalized. The ECG findings showed the pattern of type A Wellens Syndrome (Figure 1), the echocardiography indicated the ejection flow reduced at 28% with contractile dysfunction in the wall motions of the left ventricular. The cardiac enzyme hs-Troponin T was 1.00 ng/ml.
The patient was treated with enoxaparin 1 mg/kg q12hr, DAPT (81 mg Aspirin and 75 mg Clopidogrel), 40mg Rosuvastatin, 5mg Perindopril, 25mg spironolactone, low-dose of dobutamine (5mcg/kg/min) and insulin human (rDNA). The primary percutaneous coronary intervention (PCI) was performed for the patient with the angiographic result of severe and diffuse stenosis of 90-95% in proximal LAD and significant stenosis of 80-90% in proximal LCx and proximal MR (Figure 2). We decided to deploy a drug-eluting stent in the LAD based on the ECG findings of Wellens syndrome (Figure 2).
The patient was hemodynamically stable after that. On day two after PCI, the patient suddenly suffered from cardiac arrest and was treated successfully with cardiopulmonary resuscitation, three times of defibrillation, and IV adrenaline. The ECG after 30 minutes showed premature ventricular contractions (PVC) bigeminy (Figure 3), it was managed by amiodarone with 150mg IV bolus and the IV maintenance dose of 1mg/min for 6 hours and 0.5mg/min IV after that. By doing so, the ECG finding was sinus rhythm with occasional PVCs. At that time, the serum potassium and magnesium were 3.8 mmol/L and 1.1 mmol/L, respectively, which was under the IV infusion of electrolytes including 2-gram kali chloride 10% and 1.5-gram magnesium sulfate. Because of signs of congestive heart failure including rales at both lung bases, we were afraid of indicating beta-blockers for the patient.
The next day, while the patient was under treatment for a maintenance dose of amiodarone and electrolytes adjustment, he was still suffering from more than 5 times ventricular tachycardias (Figure 4) and intermittent ventricular fibrillation, which is also called cardiac electrical storm. The patient was managed with the combination of CPR and IV epinephrine, a number of defibrillations, 10mg diazepam for sedative and 1gram acetaminophen infusion of analgesics, IV potassium and magnesium, especially with the addition of one more antiarrhythmic drug called lidocaine with 1mg/kg for the bolus dose and 1mg/min for continuous infusion dose in different veins. After 30 minutes, the patient was stable hemodynamically with the sinus rhythm in ECG.
After that, we decided to transfer the patient to our cath-lab in order to perform PCI with drug-eluting stents in LCx and MR arteries (Figure 5). Thanks to the complete revascularization, the patient was stable with sinus rhythm.
The patient was followed up within a week and was discharged thanks to the hemodynamic stable condition with sinus rhythm and no arrhythmias. However, the cardiac fraction ejection did not improve. Therefore, the patient was treated with DAPT (81 mg Aspirin and 75 mg Clopidogrel), high-dose of rosuvastatin at 40mg, 5 mg of perindopril, 25mg of spinorolactone, low-dose of bisoprolol at 1.25mg, 2000 mg of Metformin and 10 mg of dapagliflozin. After 3 months of following up, the patient was stable with sinus rhythm and the cardiac function was improved from 28% to 48%, which also meant we did not indicate implantable cardioverter-defibrillator for the prevention of sudden cardiac death due to ventricular fibrillation and ventricular tachycardia.