Case 3/2017 – A 47-Year-Old Female with Refractory Heart Failure and Embolic Acute Myocardial Infarction

Clinical aspects

This case can be approached in two ways: chronic disease and acute decompensation. Taking the chronic disease way, some possible etiologies of heart failure can be considered. With the negative Chagas serology and her known comorbidities, the major hypotheses to be considered for this patient are hypertensive heart disease (dilated phase), microcirculation disease due to diabetes mellitus, and idiopathic dilated cardiomyopathy.^– The patient attended to only two medical consultations, being her complementary investigation unfinished. Now, taking the acute decompensation way, it was relatively clear at the beginning that the infectious hypothesis was the most plausible, being the elevation in the levels of myocardial necrosis markers probably related to sepsis and hemodynamic instability (type 2 acute myocardial infarction). However, after the results of the other complementary tests (echocardiography and coronary angiography), the hypothesis of acute myocardial infarction of embolic cause gained strength, mainly due to the finding of an intracavitary thrombus on the first exam. Therefore, we hypothesize that the significant left ventricular dysfunction determined the formation of the thrombus, whose fragment embolized to the coronary circulation, causing an acute myocardial infarction, culminating with dysfunction worsening, thus triggering the cascade that led to the patient’s death.

Some of the causes of coronary emboli are heart valvular disease, cardiomyopathy, coronary atherosclerosis and atrial fibrillation. In a postmortem study by Prizel et al., an intracavitary thrombus was present in 33% of the cases. Nevertheless, a superimposed infectious cause for decompensation cannot be ruled out. (João Gabriel Batista Lage, MD)

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