Hidden in Plain Sight: An Elusive Cause of Cardiogenic Shock

Patient presentation: A 54-year-old man presented to the emergency department with chest pain and shortness of breath for 3 days. The chest pain was constant, whereas the dyspnea was worse with exertion and being supine. He denied fevers, chills, or viral symptoms. His medical history included chronic obstructive pulmonary disease and previous tobacco use. On examination, he was afebrile, with a heart rate in the 90s and blood pressure 118/70 mm Hg. Oxygen saturation was 93%. Jugular veins were distended with an estimated central venous pressure of 14 cm H2O. Cardiovascular examination revealed tachycardia and an S3. Extremities were warm with 1+ bilateral lower extremity edema. He had bibasilar crackles on lung examination without wheezing. White blood cell count and basic chemistry panel were normal. B-type natriuretic peptide (1300 pg/mL, reference <150 pg/mL) and troponin I (0.06 ng/mL, reference <0.05 ng/mL) were elevated. An electrocardiogram showed sinus rhythm with normal ST segments. A chest x-ray revealed mild pulmonary edema. On review of external records, similar presentations leading to 3 hospitalizations over the past year for chest pain and dyspnea associated with mild troponin elevations were discovered. Volume overload was not reported at previous presentations; B-type natriuretic peptide was normal or mildly elevated (24–150 pg/mL). Previous workup included transthoracic echocardiogram, which demonstrated preserved left ventricular (LV) ejection fraction and mild regional hypokinesis of multiple segments in a nonvascular distribution but lacked clear echocardiographic evidence of elevated filling pressures. Coronary angiography showed mild nonobstructive coronary disease. His respiratory symptoms were attributed to chronic obstructive pulmonary disease exacerbations, for which he was prescribed brief courses of prednisone. His symptoms improved in between presentations.