ACCP-SEEK Board Review Question of the Month |

A 64-Year-Old Man Enters the ICU With Hypotension and Pulmonary Edema Associated With Persistent Chest Pain* FREE TO VIEW

Joseph Parrillo, MD, FCCP
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*From the ACCP-SEEK program, reprinted with permission. Items are selected by Department Editors Richard S. Irwin, MD, FCCP, and John G. Weg, MD, FCCP. For additional information about the ACCP-SEEK program, phone 1-847-498-1400.

Chest. 1999;116(5):1459-1460. doi:10.1378/chest.116.5.1459
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A 64-year-old man enters the ICU with hypotension and pulmonary edema. He has a 5-year history of intermittent angina treated with nitroglycerin. Two years ago, the patient had an ECG showing T-wave inversions in leads II, III, and AVF. An echocardiogram showed inferior wall hypokinesia, and he was presumed to have sustained an inferior wall myocardial infarction. This morning he developed severe chest pain and came to the hospital. His ECG demonstrated ST-segment elevation in V1 to V4, and he was given aspirin and thrombolytic therapy with tissue plasminogen activator. However, his chest pain continued, and he developed hypotension and pulmonary edema. Pulmonary artery catheterization reveals a cardiac index of 1.7 L/min/m2 and a pulmonary artery occlusion pressure of 32 mm Hg. Echocardiography reveals akinesia of the inferior and anterior walls. An intra-aortic balloon pump is placed, and the patient is taken to the cardiac catheterization laboratory. Angiography reveals severe three-vessel disease with 80% obstruction of the left anterior descending coronary artery, 90% obstruction of the left circumflex artery, and 95% obstruction of the right coronary artery. Three-vessel coronary artery bypass surgery is performed, and the patient’s cardiogenic shock resolves. He goes home on the eighth postoperative day.

Six months later, an echocardiogram reveals normal overall cardiac function (ejection fraction 58%) with no significant wall motion abnormalities. The cause of this patient’s akinetic inferior wall during cardiogenic shock was:

A. Myocardial infarction

B. Stunned myocardium

C. Hibernating myocardium

D. Reperfusion injury

E. Oxygen free radical-induced injury

Answer: C. Hibernating myocardium.

Myocardial ischemia can result in three possible effects on myocardial function: myocardial infarction, hibernating myocardium, or stunned myocardium. In this case, we are asked the cause of the inferior wall akinesia during cardiogenic shock. The patient has a history of inferior wall hypokinesis on echocardiogram from 2 years ago and is presumed to have had an old myocardial infarction. However, with surgical revascularization of his coronary arteries, his inferior wall reverts to normal function. Thus, this inferior hypokinesia was due to hibernating myocardium, a persistent wall motion abnormality due to chronic ischemia (reduced myocardial blood flow) without infarction. In hibernating myocardium, coronary flow is sufficient to maintain myocardial cell viability but not enough to allow contractile function.

Stunned myocardium refers to transient (hours to days) reductions in myocardial function, usually due to a brief reduction in coronary flow. This may occur during transient coronary thrombotic occlusion, coronary vasospasm, ischemic cardiac arrest, or cardiopulmonary bypass. In this case, the anterior wall akinesia is due to stunning, since restoration of coronary flow with bypass surgery results in normal myocardial contraction on follow-up echocardiography. Although the mechanism responsible for stunning has not been fully elucidated, oxygen free radicals and other postulated mechanisms of reperfusion injury (eg, activated neutrophils and endothelial injury) are thought to be important in this process. A similar reversible form of myocardial depression has been seen during septic shock.

Hibernating and stunned myocardium both result in significant but reversible myocardial depression. Patients with cardiogenic shock may have cardiac depression due to these reversible processes, and it is important to recognize their presence when deciding management. Thus, reperfusing hibernating myocardium (with angioplasty and/or surgery) and supporting stunned myocardium (with inotropes, intra-aortic balloon pumping, or other ventricular assist devices) provides potentially effective management of shock due to myocardial ischemia.

Braunwald E. The stunned myocardium: newer insights into mechanism and clinical applications. J Thorac Cardiovasc Surg 1990; 100:310–321.

Fournier C, Boujon B, Hebert J, et al. Stunned myocardium following coronary spasm. Am Heart J 1991; 121:593–594.

Patel B, Kloner RA, Przyklenk K, et al. Postischemic myocardial“ stunning”: a clinically relevant phenomenon. Ann Intern Med 1988; 108:626–627.

Rahimtoola SH. The hibernating myocardium. Am Heart J 1989; 117:211–221.




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