# Clinical Cases: Cardiac Emergencies

## Case 1: Anterior STEMI with Cardiogenic Shock

### Patient Demographics
- **Age:** 62 years
- **Sex:** Male
- **Occupation:** Construction manager

### Chief Complaint
"Crushing chest pain for 45 minutes."

### History of Present Illness
A 62-year-old male presents via EMS with severe substernal chest pain that began suddenly while at work. He describes the pain as "crushing" and "like an elephant sitting on my chest," radiating to his left arm and jaw. Associated with diaphoresis, nausea, and shortness of breath. Pain is 10/10 and unrelieved by rest. Risk factors include smoking (40 pack-years), hypertension, and family history of MI (father at age 55).

### Initial Assessment

**ESI Level:** 1 - Immediate life-threatening condition

**Vital Signs:**
- Heart rate: 110 bpm, regular
- Blood pressure: 88/54 mmHg
- Respiratory rate: 26 breaths/min
- SpO2: 91% on room air
- Temperature: 36.8C

**First Impression:**
- Diaphoretic, pale, clutching chest
- Appears acutely distressed
- Speaking in short phrases

### Primary Survey and Initial ECG

**Door-to-ECG Time:** 4 minutes

**ECG Findings:**
- Sinus tachycardia at 110 bpm
- ST elevation in V1-V4 (4-6mm)
- ST elevation in aVL (2mm)
- Reciprocal ST depression in II, III, aVF
- No pathological Q waves yet

**Interpretation:** Acute anterolateral STEMI - LAD occlusion

### STEMI Time Targets

| Target | Actual | Met |
|--------|--------|-----|
| Door-to-ECG <10 min | 4 min | Yes |
| Door-to-Cath Lab activation <10 min | 6 min | Yes |
| Door-to-Balloon <90 min | 52 min | Yes |

### Management

**Immediate Interventions (within 10 minutes):**
1. High-flow oxygen (SpO2 <94%)
2. Aspirin 325mg chewed
3. IV access x2
4. Continuous cardiac monitoring
5. 12-lead ECG with right-sided leads (V4R)
6. Cath lab activated - STEMI alert

**Adjunctive Therapy:**
- Ticagrelor 180mg PO loading dose
- Heparin 60 units/kg bolus (max 4000 units)
- Sublingual nitroglycerin withheld (SBP <90)
- No morphine given (concern for hemodynamic effects)

**Cardiogenic Shock Management:**
- Norepinephrine infusion started for MAP <65
- Careful fluid challenge (250mL bolus - no improvement)
- Dobutamine added for inotropy

### Cardiac Catheterization Findings

- 100% occlusion of proximal LAD
- Moderate disease in RCA (70%)
- Successful PCI with drug-eluting stent to LAD
- TIMI 3 flow restored
- IABP placed for cardiogenic shock support

### Post-PCI Course

**Echo (24 hours):**
- EF 30% (severely reduced)
- Anterior and apical akinesis
- No mechanical complications

**Hospital Course:**
- Weaned off IABP day 3
- Vasopressors discontinued day 4
- Started on guideline-directed medical therapy:
  - ACE inhibitor (captopril)
  - Beta-blocker (metoprolol - uptitrated slowly)
  - High-intensity statin (atorvastatin 80mg)
  - DAPT (aspirin + ticagrelor)
- Smoking cessation counseling
- Cardiac rehabilitation referral
- ICD evaluation at 40 days post-MI

### Teaching Points

1. **Time is muscle:** Every minute of LAD occlusion causes ~1.9 million cardiomyocyte deaths
2. **STEMI equivalents:** Recognize anterolateral pattern - reciprocal changes in inferior leads
3. **Cardiogenic shock management:** Requires vasopressors/inotropes AND revascularization - PCI is definitive therapy
4. **Avoid nitroglycerin in hypotension:** Check BP before and after each dose
5. **IABP for cardiogenic shock:** Bridge to recovery or further intervention

### Clinical Image
![Anterior STEMI ECG](case_01_image.jpg)

**Image Description:** 12-lead ECG demonstrating acute anterior STEMI with ST-segment elevation in leads V1-V4 and aVL, with reciprocal ST depression in inferior leads, consistent with proximal LAD occlusion.

**Attribution:** Image from Wikimedia Commons, ECG of anterior myocardial infarction. Public domain. Source: https://commons.wikimedia.org/wiki/File:AMI_anterior_ST_elevation.jpg

---

## Case 2: Unstable Ventricular Tachycardia

### Patient Demographics
- **Age:** 55 years
- **Sex:** Female
- **Occupation:** Office administrator

### Chief Complaint
"My heart is racing and I feel like I'm going to pass out."

### History of Present Illness
A 55-year-old female presents with sudden onset of palpitations and lightheadedness that began 20 minutes ago. She has a history of "heart problems" and takes "heart medications" but cannot recall the names. She feels weak, has mild chest discomfort, and nearly fainted in the waiting room.

### Initial Assessment

**ESI Level:** 1 - Unstable tachyarrhythmia

**Vital Signs:**
- Heart rate: 188 bpm, regular
- Blood pressure: 76/48 mmHg
- Respiratory rate: 24 breaths/min
- SpO2: 94% on room air
- GCS: 14 (oriented but confused)

**Cardiac Monitor:**
- Wide complex tachycardia
- QRS duration ~160ms
- Regular rhythm

### Rhythm Analysis

**ECG Characteristics:**
- Rate: 188 bpm
- Regular wide complex tachycardia
- QRS >120ms (wide complex)
- AV dissociation present
- Fusion beats noted

**Diagnosis:** Monomorphic Ventricular Tachycardia

### Stability Assessment

**UNSTABLE - Immediate cardioversion indicated:**
- Hypotension (SBP <90)
- Altered mental status
- Signs of hypoperfusion
- Chest discomfort

### Management

**Immediate Actions:**
1. IV access established
2. Pads placed in anterior-lateral position
3. Procedural sedation: Etomidate 0.2 mg/kg IV push

**Synchronized Cardioversion:**
- Energy: 100J biphasic (synchronized)
- Successful conversion to sinus rhythm on first shock

**Post-Cardioversion ECG:**
- Sinus rhythm at 78 bpm
- QRS 110ms (baseline LBBB)
- QTc 480ms
- Old anteroseptal infarct pattern

**Post-Cardioversion Vitals:**
- BP: 118/72 mmHg
- HR: 78 bpm
- Mental status: Alert, oriented
- Chest discomfort resolved

### Further Workup

**Labs:**
- Troponin: 0.08 ng/mL (mildly elevated)
- K: 3.2 mEq/L (low)
- Mg: 1.6 mg/dL (low-normal)
- BNP: 580 pg/mL (elevated)

**Echocardiogram:**
- EF 25%
- Anteroseptal and apical akinesis
- Dilated LV

**History (from family):**
- Prior MI 5 years ago
- Known cardiomyopathy
- On metoprolol, lisinopril, furosemide
- Recently ran out of medications

### Diagnosis

**Monomorphic Ventricular Tachycardia** secondary to:
- Ischemic cardiomyopathy (scar-mediated reentry)
- Hypokalemia (medication non-compliance)

### Hospital Management

1. Telemetry monitoring
2. Amiodarone loading (150mg IV, then infusion)
3. Potassium and magnesium repletion
4. Resume GDMT medications
5. Cardiology consultation for ICD evaluation

### Disposition

- ICU admission for monitoring
- Discharged day 4 with ICD implanted
- Outpatient EP follow-up

### Teaching Points

1. **Wide complex tachycardia = VT until proven otherwise:** Especially with cardiac history
2. **Unstable = immediate cardioversion:** Don't delay with medications
3. **Synchronization is critical:** Prevents shock during vulnerable period (R-on-T phenomenon)
4. **Find and fix reversible causes:** Electrolyte abnormalities are common triggers
5. **ICD for secondary prevention:** Anyone surviving VT/VF arrest with structural heart disease

### Clinical Image
![Ventricular Tachycardia ECG](case_02_image.jpg)

**Image Description:** 12-lead ECG demonstrating monomorphic ventricular tachycardia with wide QRS complexes, regular rhythm, and AV dissociation.

**Attribution:** Image from Wikimedia Commons, ECG showing ventricular tachycardia. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Ventricular_tachycardia.png

---

## Case 3: Cardiac Tamponade

### Patient Demographics
- **Age:** 45 years
- **Sex:** Male
- **Occupation:** Sales representative

### Chief Complaint
"I can't catch my breath and I feel like I'm going to die."

### History of Present Illness
A 45-year-old male presents with 3 days of progressive dyspnea and chest discomfort. He had a "viral illness" 2 weeks ago with fever, body aches, and sore throat that resolved. Over the past few days, he developed worsening shortness of breath, especially when lying flat, and a dull chest ache. Today he feels extremely weak and nearly passed out at home.

### Initial Assessment

**ESI Level:** 1 - Critical, hemodynamically unstable

**Vital Signs:**
- Heart rate: 122 bpm
- Blood pressure: 82/64 mmHg
- Respiratory rate: 28 breaths/min
- SpO2: 92% on room air
- Pulsus paradoxus: 22 mmHg

### Physical Examination

**Beck's Triad Present:**
1. Hypotension (SBP 82)
2. Jugular venous distension (JVP to angle of jaw)
3. Muffled heart sounds

**Additional Findings:**
- Tachypnea, using accessory muscles
- Clear lung fields (no pulmonary edema)
- Cool extremities, weak pulses
- No peripheral edema

### Diagnostic Evaluation

**ECG:**
- Sinus tachycardia
- Low voltage QRS complexes
- Electrical alternans (alternating QRS amplitude)

**Chest X-ray:**
- Enlarged cardiac silhouette ("water bottle" configuration)
- Clear lung fields

**Bedside Echocardiography:**
- Large circumferential pericardial effusion
- Right atrial collapse during late diastole
- Right ventricular diastolic collapse
- IVC plethora (>2.1cm, <50% collapse)
- Swinging heart motion

### Diagnosis

**Cardiac Tamponade** secondary to viral pericarditis (presumed)

### Management

**Immediate Stabilization:**
1. IV fluid bolus (500mL) - transient improvement
2. Avoid positive pressure ventilation if possible
3. Prepare for emergent pericardiocentesis
4. Cardiothoracic surgery on standby

**Pericardiocentesis:**
- Subxiphoid approach under ultrasound guidance
- 18-gauge needle advanced at 45-degree angle toward left shoulder
- 650mL of serosanguinous fluid aspirated
- Pigtail drain left in place

**Immediate Response:**
- BP improved to 112/74 mmHg
- HR decreased to 92 bpm
- JVD resolved
- Marked symptomatic improvement

### Pericardial Fluid Analysis

- Appearance: Serosanguinous
- WBC: 2,400/mm3 (lymphocyte predominant)
- Protein: 4.2 g/dL (exudate)
- Glucose: 68 mg/dL
- LDH: 380 U/L
- Cytology: Negative for malignancy
- Cultures: No growth

### Hospital Course

- Drain output decreased over 3 days
- Drain removed day 4
- Started on colchicine 0.5mg BID and ibuprofen 600mg TID
- Echo prior to discharge: Small residual effusion, no tamponade physiology
- Discharged day 5

### Final Diagnosis

**Cardiac tamponade secondary to viral (idiopathic) pericarditis**

### Teaching Points

1. **Beck's triad:** Classic but not always complete - JVD, muffled heart sounds, hypotension
2. **Pulsus paradoxus >10mmHg:** Highly suggestive of tamponade physiology
3. **Electrical alternans:** Pathognomonic ECG finding due to swinging heart
4. **Bedside echo is diagnostic:** Right chamber collapse, IVC plethora
5. **Avoid positive pressure ventilation:** Worsens venous return and hemodynamics
6. **Pericardiocentesis is life-saving:** Even small volume removal dramatically improves hemodynamics

### Clinical Image
![Pericardial Effusion on Echocardiography](case_03_image.jpg)

**Image Description:** Echocardiogram (parasternal long axis view) demonstrating a large circumferential pericardial effusion with right ventricular diastolic collapse, consistent with cardiac tamponade.

**Attribution:** Image from Wikimedia Commons, Echocardiogram showing pericardial effusion. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Pericardial_effusion_with_tamponade.jpg