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Acute reversible pulmonary hypertension and right heart failure from cocaine toxicity

Case contributed by Jayanth Keshavamurthy
Diagnosis certain


Acute chest pain today on a background of overnight cocaine use; associated hypotension and ST elevation on ECG.

Patient Data

Age: 40 years
Gender: Female

Acute ST wave elevation in anterior leads from cocaine-induced coronary vasospasm.

Labs: high troponin, positive drug screen for cocaine and THC.

There is mild cardiomegaly, primarily due to right-sided chamber enlargement, with straightening of the intraventricular septum and increase in the RV/LV ratio; associated reflux of IV contrast into the infrahepatic IVC and hepatic veins is present. No central or segmental pulmonary embolism is present. There is no thoracic aortic aneurysm or dissection. There is no pericardial effusion. 

Procedures performed: Right and Left Heart catheterization with coronary angiography and left ventriculogram

Preserved LV systolic function
Non-obstructive epicardial coronaries
Elevated right heart filling pressures
Significant step up in oxygen saturation between RA and PA.
Decreased cardiac output/index

Left Heart Assessment
Left Ventricular End Diastolic Pressure 20 mmHg
Left Ventricular Ejection Fraction: 60%
LV Wall Motion: Normal
Right Heart Assessment
Fick CO: 1.86 Fick CI: 1.12
PCW: 23/20 16
PA: 23/14 17
RV: 24/14 17
RA: 22/30 18
PVR: 36 SVR: 1764

Coronary Angiography:




Findings on echocardiogram.

There is mild to moderate concentric left ventricular hypertrophy. Left ventricular systolic function is moderately reduced. LVEF is 30-35%. There is global hypokinesis.

There is flattening of the interventricular septum, consistent with RV overload. The right ventricular size is moderately to severely dilated. The right ventricular function is severely reduced.

Injection of agitated saline contrast documented no interatrial or intrapulmonary shunt. The right atrium is moderately dilated. There is mild to moderate tricuspid regurgitation. There is a small posterior pericardial effusion.

Case Discussion

Adult female who started having chest pain in the setting of using cocaine overnight. No significant past medical history. She presented to the ED with hypotension and ST elevation. Peak troponin level was 45.

STEMI code was called with stat transfer to the cardiac cath lab, which showed non-obstructive coronaries. Right heart catheterization did show a severely elevated pulmonary artery pressure.

Transthoracic echocardiogram showed a dilated and severely depressed right ventricle. After left heart catheterization the patient remained hypotensive and so was started on norepinephrine.

Concern was made for possible PE vs shunt given right atrial oxygen saturation was mid-to-high 20s and pulmonary artery saturation was mid-30s.

CTPA was obtained, which was negative for PE. Bubble study was obtained with TTE, which was negative for a shunt.

The patient remained on pressors. A right radial arterial line was placed and RIJ TLC was placed. She was transferred to a cardiac center for possible RVAD or transplant.

The patient improved with treatment and was discharged one week later from there without RVAD, ECMO or cardiac transplant.

See reference 1 below, this is a similar case.

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