Inferior STEMI with right ventricular infarction and cardiogenic shock in a patient with recent GI bleeding
A 62-year-old man with hypertension and a 30 pack-year smoking history presents 4 hours after sudden crushing chest pain. The ECG shows 2–3 mm ST elevation in leads II, III and aVF with reciprocal depression in I and aVL, and 1 mm ST elevation in V4R. Blood pressure is 86/54 mmHg, pulse 112/min and regular, JVP 9 cm, lungs clear on auscultation and chest radiograph. Three weeks ago he had an upper GI bleed (haemoglobin 7.8 g/dL, transfused 2 units) and now takes only omeprazole. Current haemoglobin is 8.9 g/dL, platelets 210 × 10⁹/L, creatinine 130 µmol/L, lactate 4.1 mmol/L. The catheter laboratory is 20 minutes away and fully staffed. He is anxious and has received no antiplatelet or anticoagulant therapy yet. A bed in the coronary care unit is available and a perfusionist-supported Impella programme exists on site.
1. What is the diagnosis and how does it change your immediate management, including during transfer?
Read the worked answer
The diagnosis is acute inferior STEMI with right ventricular involvement complicated by cardiogenic shock (hypotension, raised JVP with clear lungs, lactate 4.1). The RV infarct makes the right ventricle preload-dependent and stroke-volume-limited. Management points:
- Reperfusion: primary PCI is the strategy of choice. Thrombolysis is contraindicated by the recent GI bleed, and PCI is superior in shock anyway. Activate the lab for a door-to-balloon time under 90 minutes.
- Preload first, no venodilators: give a cautious fluid bolus of 250–500 mL crystalloid and reassess JVP, blood pressure and lungs. Nitrates, diuretics and morphine in volume-depleting doses are contraindicated and commonly precipitate collapse.
- If hypotension persists after fluid: start an inotrope (dobutamine) and/or a vasopressor (noradrenaline) to maintain MAP ≥65 mmHg; do not chase a normal blood pressure with fluid alone once the lungs become wet.
- Antiplatelets: load aspirin 300 mg plus clopidogrel 300–600 mg. Prefer clopidogrel over ticagrelor/prasugrel because of the recent GI bleed, and do not give glycoprotein IIb/IIIa inhibitors.
- Supportive care: continuous ECG monitoring for complete AV block (common in inferior MI), cross-match blood, restart/increase PPI, and avoid NSAIDs.
- Transfer: move to the lab with monitoring, resuscitation drugs and a defibrillator; the fluid bolus and vasopressor should be running before departure.
2. Two hours after successful RCA stenting he remains hypotensive on noradrenaline 0.2 µg/kg/min with a lactate of 5 mmol/L. What is your escalation plan, and how do you decide about mechanical support?
Read the worked answer
Persistent hypotension and rising lactate after reperfusion indicate ongoing cardiogenic shock, so reassess rather than simply increasing vasopressors.
Step 1 - exclude mechanical complications and other causes: bedside echo for pericardial effusion/tamponade, severe tricuspid regurgitation, ventricular septal rupture, and assessment of LV and RV function. Check for bleeding (falling haemoglobin, re-look at the access site and the GI tract), arrhythmia, and adequacy of preload.
Step 2 - optimise pharmacology: noradrenaline to MAP ≥65 mmHg, add dobutamine for low cardiac output, keep the patient intubated/ventilated if needed, correct acidosis and electrolytes.
Step 3 - mechanical circulatory support: he has a reasonable chance of recovery, so a temporary device is justified. An intra-aortic balloon pump is not routinely indicated in AMI shock (IABP-SHOCK II), but remains useful for mechanical complications such as VSR or acute MR. A percutaneous microaxial pump (Impella) is reasonable for refractory shock with a potentially recoverable ventricle, but evidence of mortality benefit is limited and it carries haemolysis, limb ischaemia and bleeding risks. An ECMO team should be involved early if there is refractory hypoxaemia or biventricular failure.
Step 4 - decision criteria: age, comorbidity, neurological status, duration of shock, and whether the myocardium is recoverable. Escalate early rather than after multi-organ failure, and hold a documented goals-of-care discussion with the family.
3. How does the recent GI bleed influence your antithrombotic prescription at discharge, and what follow-up do you arrange?
Read the worked answer
The recent bleed puts him in a high bleeding-risk category (recent bleeding within 3 months, anaemia, age), so the default potent P2Y12 inhibitor is not appropriate. Discharge on:
- Aspirin 75–100 mg daily plus clopidogrel 75 mg daily, with the duration guided by ischaemic risk: 12 months in a conservatively treated patient, but 1–3 months may be acceptable if bleeding recurs or after complex PCI with high bleeding risk.
- No anticoagulation unless there is another indication (e.g. atrial fibrillation, LV thrombus) - none here.
- PPI (omeprazole or pantoprazole) for the duration of dual therapy, and treat/eradicate H. pylori if positive.
- Correct anaemia: oral or intravenous iron, and consider transfusion to a higher threshold than usual if symptomatic; check haemoglobin before discharge.
- Avoid NSAIDs, and warn about the warning signs of GI bleeding.
- Secondary prevention: high-intensity statin, ACE inhibitor and beta-blocker, smoking cessation, cardiac rehabilitation, and repeat echocardiography to assess LV function (which determines later ICD consideration if EF ≤35% persists at 3 months).
- Follow-up: cardiology at 4–6 weeks with FBC, a clear written plan for when to stop clopidogrel, and a documented shared decision that balances recurrent bleeding against stent thrombosis.