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A rare and dangerous presentation of alcoholic cardiomyopathy

Session Poster Session 4

Speaker Helen Liu

Event : Heart Failure 2019

  • Topic : heart failure
  • Sub-topic : Chronic Heart Failure - Clinical
  • Session type : Poster Session

Authors : H Liu (Toronto,CA), VK Le (Thunder Bay,CA), M Sadreddini (Thunder Bay,CA)

Authors:
H Liu1 , VK Le2 , M Sadreddini2 , 1University of Toronto - Toronto - Canada , 2Northern Ontario School of Medicine - Thunder Bay - Canada ,

Citation:

Introduction and case report description: A left ventricular thrombus is a serious complication that can occur after a myocardial infarction or due to cardiomyopathy. This complication is more commonly associated with a large anterior STEMI due to occlusion of the left anterior descending artery, and usually occurs five to six days after a myocardial infarction. However, it is important to remember that this complication can also occur due to cardiomyopathy and heart failure.

A 38-year-old male no past medical history presented to a rural emergency department with sudden severe chest pain, along with several months of slowly worsening peripheral edema. The patient drank 12 to 18 bottles of beer daily for the past 6 months. An electrocardiogram showed ST elevation in leads II, III, and aVF. He was given tenecteplase, along with aspirin, clopidogrel, and IV heparin, and then transported to a hospital with access to percutaneous coronary intervention. The patient developed new aphasia and right hemiparesis during his assessment on arrival to the larger hospital.

Description of the problem and differential diagnosis: A Code Stroke was called, and the patient’s head CT did not show an intracranial bleed. Point-of-care ultrasound showed reduced left ventricular function with an ejection fraction of 19% and a large apical thrombus measuring 5.5 x 3.1 x 2.6 cm.

The patient’s neurological symptoms resolved with anticoagulation after 5 days. Serial echocardiograms showed a decrease in thrombus size. After four weeks, the heparin was switched to warfarin and the patient was discharged in a stable condition.

The patient’s significant long-term alcohol use resulted in alcoholic cardiomyopathy, as indicated by the several months of progression of lower extremity edema and severe left ventricular dysfunction on echocardiogram. The ventricular dysfunction resulted in reduced blood flow, which is one of the components of Virchow’s triad, and contributed to the formation of the large apical thrombus. Eventually part of the clot broke off the thrombus, occluded the right coronary artery, and caused the inferior STEMI. Shortly after, another piece of the thrombus broke off and resulted in a cardioembolic stroke to the left middle cerebral artery.

Conclusions and implications for clinical practice: In patients who have multiple simultaneous illnesses, it is important to evaluate for a unifying diagnosis, such as in this case where the patient’s alcoholic cardiomyopathy resulted in a thrombus formation, which caused both the inferior STEMI and the ischemic stroke. 

This case also highlights the clinical benefits of being proficient in performing a point-of-care ultrasound because a bedside echocardiogram by the receiving physician only took a few minutes and found the left ventricular dysfunction and large thrombus. This finding, along with the clinical history, resulted in a unifying diagnosis for this patient’s medical condition.

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