Arq. Bras. Cardiol. 2019; 113(4): 775-782

Case 5/2019 – 55-Year-Old Diabetic Man with Heart Failure After Non-ST Segment Elevation Myocardial Infarction

Ana Vitória Vitoreti Martins , José Roberto de Oliveira da Silva , Paulo Sampaio Gutierrez

DOI: 10.5935/abc.20190225

Clinical Aspects

This is a 55-year-old male patient known to have insulin dependent DM and CKD who in February 2017 had a nocturnal episode of dyspnea. Due to the episode, he sought medical care in the emergency room, where changes in markers of myocardial necrosis were identified – increased CKMB and troponin, as well as ST-segment depression from V₂ to V₆ on the ECG. A coronary angiography was performed at the time showing only a 30% lesion in the right coronary artery.

After discharge, the patient developed orthopnea and lower limb edema requiring further hospitalization seven days after discharge. On admission to our service, he presented signs of pulmonary and systemic congestion, the ECG maintained previous parameters, a chest X-ray showed cardiomegaly and massive bilateral pleural effusion, and laboratory tests showed a worsening of renal function and anemia. The transthoracic echocardiogram showed 22% LVEF, through the Simpson method, with diffuse hypokinesia and no segment changes. After this initial evaluation, the following hypothesis was raised for this patient – type 2 AMI and myocarditis. In order to enable a better investigation of the patient´s conditions, propaedeutic complementation was performed. The serologies for Chagas disease and cytomegalovirus were negative. A cardiac resonance showed increased systolic dysfunction in both ventricles with 11% LVEF, with slight left ventricular dilation, increased right ventricular dilation, a significant enlargement of the left atrium and an absence of changes in the right atrium. Regarding the enhancement, the patient presented late transmural, circumferential multifocal enhancement, with subendocardial involvement sparing the apex. There was no pericardial effusion, but there was massive bilateral pleural effusion.

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