Cardiogenic Shock and Pulmonary Edema due to Subacute Anterior STEMI

This is a 72 yo male whose symptoms began with a cough 12 hours prior to presentation, at which time he had CP, SOB, and resp distress. On evaluation, he had pulmonary edema and progressive hypotension. His first ECG at 0714 is shown here:

There are QS-waves in V1 and V2, and ST elevation in V1-V3. This morphology is suggestive of either old anterior MI with persistent ST elevation or subacute anterior STEMI. There was a previous ECG on file from one year previous:

This ECG is comparatively normal, without QS-waves or ST elevation. So, at some time between one year ago and the time of presentation, the patient suffered a large anterior MI. That he felt fine until 12 hours ago strongly suggests that the MI began at that time.

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The patient was aggressively supported with mechanical ventilation and pressors. A bedside echo confirmed antero-apical wall motion abnormality. His first troponin returned at 10 ng/ml, confirming subacute anterior STEMI. He went to the cath lab and was found to have a "chronic total LAD occlusion" that received flow from collaterals from the RCA. There was severe 3-vessel disease and also left main disease. A balloon pump was placed and he went for CABG. Here is his post cath ECG.

The ST elevation is resolved. He remains very tachycardic. He is still intubated now. The troponin peaked at 177 ng/ml.

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There was clearly a very significant coronary event. Formal echo confirmed new anterior wall motion abnormality. ST elevation resolved after flow was restored. This was a very large anterior transmural STEMI. One must wonder whether the occlusion was definitely chronic. Clearly, the interventionalist could not cross it with the wire. The exact culprit lesion was not found.