Reactions Weekly | 2021
Multiple drugs
Abstract
Lack of efficacy: case report A 40-year-old woman exhibited lack of efficacy during treatment with eptifibatide, sodium-nitroprusside and epinephrine for acute ST segment elevation myocardial infarction and during treatment with norepinephrine for cardiogenic shock [dosages not stated; not all routes stated]. The woman, who had a history of hypertension, diabetes mellitus, hyperlipidaemia and paranoid schizophrenia presented to an emergency department with retrosternal chest pain, cough and shortness of breath. She was afebrile, normotensive, but tachycardic and hypoxic. Electrocardiogram revealed left ventricular hypertrophy and sinus tachycardia. Chest X-ray findings were consistent with pneumonia. She was admitted with COVID-19 pneumonia and to exclude acute coronary syndrome, she received aspirin and clopidogrel. On day 2, she reported worsening chest pain. An ECG revealed sinus tachycardia, new right bundle branch block and ST-segment elevation in lateral, anterior and inferior leads. She received maintenance dual antiplatelet therapy and heparin [unfractionated heparin]. She was transferred for emergent cardiac catheterization. Transradial coronary angiography showed a thrombotic occlusion at the ostium of the left anterior descending (LAD) artery. She received bivalirudin and a compliant balloon was used. Angiogram revealed an extensive thrombus along the entire length of the LAD and large diagonal arteries. Subsequently, she received pretreatment with intracoronary sodium-nitroprusside [nitroprusside]. She underwent mechanical powered aspiration thrombectomy, but no improvement was noted in thrombus burden. She received alteplase. Five minutes later, a repeat angiogram revealed persistent thrombus. She underwent repeat aspiration thrombectomy. Her thrombus in the proximal and mid LAD was resolved, but persistent thrombus was observed in the distal segment of the LAD. She was intubated for refractory hypoxia and a drug-eluting stent was placed in the proximal LAD and postdilated with a noncompliant balloon. She was noted with thrombus embolization thereafter, in distal left circumflex artery (LCx). Alteplase was administered in the LCx. An intra-aortic balloon pump (IABP) was placed due to persistent hypotension. Subsequently, new thrombus was formed in the recently implanted LAD stent. Additionally, she received alteplase and the recurrent proximal thrombus was resolved. She received intracoronary eptifibatide, sodium-nitroprusside and epinephrine in the distal coronary bed of the LAD and LCx. Despite the treatment, no reflow was observed in the distal coronary bed of the LAD and LCx (lack of efficacy). Examinations revealed a cardiac index of 1.7 L/min/m2, despite the use of IABP and treatment with norepinephrine (lack of efficacy). An echocardiogram revealed akinesis and diffuse hypokinesis. She was transferred to an ICU for management of cardiogenic shock and COVID-19 pneumonia. She died 48 hours after percutaneous coronary intervention with cardiogenic shock and septic shock.