ICU will not take the patient

An 88 yo patient who is fully independent, is brought into ED by ambulance in Cardiogenic Shock. The only past history the patient has is hypertension and hypercholesterolaemia.

Earlier that morning the patient developed central chest pain and felt dizzy. When the ambulance arrived the patient had the following vitals:

• Afebrile
• HR 72bpm
• BP 65/42
• Sats 97% on Room air.

ECG showed a normal sinus rhythm with no ST elevation or depression.

Following an unsuccessful fluid challenge, the ambulance commenced Adrenaline and gave Aspirin.

On arrival to the ED the patient is still complaining of chest pain and has the following vitals:

• HR 128bpm
• BP 132/68

There are still no signs of ischaemia on the ECG, it is normal sinus rhythm.

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What percentage of patients with early AMI have ECG changes?

What percentage of patients with proven MI( history and Troponin) do not develop ST elevation or Depression?

What would you do now?

 We talk about advanced directives and what they mean.

We also talk about Troponins and mortality.

Kaura et al. Association of troponin level and age with mortality in 250000 patients; cohort study across five UK acute care centres. BMJ 2019;367:16055

The hazard ratio for a high troponin is highest in the younger patients and decreases in the elderly. Why would that be?

Much of the literature quotes one study from 1999:

Hochman J et al. Early revascularisation in acute myocardial infarction complicated by cariogenic shock. August 26, 1999, 341(9): 625-634.

We also look at another study:

Ratcovich HL et al. Outcome in elderly patients with cardiogenic Shock Complicating Acute myocardial Infarction.Shock March 2022 57(3);327-335.

We look at the CardShock study:

Harjola V-P et al. Clinical picture and risk prediction of short term mortality in cardiogenic shock. Europe J Heart Fail. 2015. 17: 501-509

Finally we look at the American Heart Association statement:

Cardiogenic Shock in Older Adults: A Focus on Age-Associated Risks and Approach to Management: A Scientific Statement From the American Heart Association. Circulation 2024;149:e1051-e1065