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.