RAPID VENTRICULAR RUPTURE SECONDARY TO COCAINE-INDUCED NSTEMI

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Ventricular septal rupture (VSR) is an exceedingly rare complication, occurring after 0.2-0.4% of myocardial infarctions. These cases are classically noted after transmural infarction, in the setting of coronary artery disease (CAD). Few cases have described VSR secondary to NSTEMIs, in the setting of cocaine abuse. CASE PRESENTATION: A 68 year old female with a history of cocaine abuse & hypertension, & multiple prior admissions for cocaine detoxification presented to the ER with a 5 day history of intractable abdominal pain & emesis. On arrival to the ER, the patient was in sinus tachycardia, with normotension. Chest x-ray was unremarkable. EKG demonstrated a right bundle branch block, & Q waves in the anteroseptal leads (which were absent on prior EKGs in 2019). No ST elevations were noted. Initial troponin was markedly elevated at 149. While in the ER, she went into PEA arrest, prompting CPR & intubation. ROSC was achieved & hemodynamic support was initiated. The patient coded twice more thereafter. The cardiology team performed a STAT (bedside) echocardiogram, which was remarkable for a muscular ventricular septal defect. The plan was for emergent left & right heart catheterization, & impella placement. Unfortunately, the patient developed cardiac arrest yet again, & was pronounced dead prior to transfer to the interventional suite, 9 hours after arrival. Though urine toxicology was not processed, cocaine was reportedly found in the patient's belongings. Of note, formal transthoracic echocardiogram performed in 2019 demonstrated an ejection fraction of 60%, and grade 1 diastolic dysfunction. There were no signs of regurgitation, stenosis, or septal defect at that time. No cardiac catheterization was noted on file. DISCUSSION: Cocaine is unquestionably cardiotoxic, with direct ties between abuse & myocardial infarction (MI). However, no connection between cocaine & VSR has been established. However, studies have demonstrated histologic signs of direct toxicity to the myocardium itself, with evidence of myofibril destruction & sarcoplasmic vacuolization [1]. We propose that chronic cocaine abuse disrupted the integrity of this patient's myocardial tissue, rendering her susceptible to VSR after sustaining an NSTEMI. Cardiac rupture of any kind (free wall, or VSR) is rare in itself, but the incidence rate is 5 times lower without ST elevation [2]. Other risk factors that placed our patient at risk for VSR included female gender, increased age, & this first (known) episode of MI. Other (non-applicable) risk factors include a high GRACE score, chronic kidney disease, & ST elevation [3]. CONCLUSIONS: Though relatively rare, VSR remains a life threatening complication of MI, with staggering mortality rates. Despite being traditionally associated with transmural infarction & coronary artery disease, VSR should remain in the differential in patients who present with NSTEMI, and/or cocaine abuse. REFERENCE #1: Peng SK, French WJ, Pelikan PC. Direct cocaine cardiotoxicity demonstrated by endomyocardial biopsy. Arch Pathol Lab Med. 1989 Aug;113(8):842-5. REFERENCE #2: José López-Sendón, J., Gurfinkel, E., Global Registry of Acute Coronary Events (GRACE) Investigators, Factors related to heart rupture in acute coronary syndromes in the Global Registry of Acute Coronary Events, European Heart Journal, Volume 31, Issue 12, June 2010 REFERENCE #3: Mubarik A, Iqbal AM. Ventricular Septal Rupture. [Updated 2021 Mar 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan DISCLOSURES: No relevant relationships by Nakeya Dewaswala, source=Web Response No relevant relationships by Christopher Siriphand, source=Web Response No relevant relationships by Christopher Wood, source=Web Response