A 72-year-old woman with diet-controlled type 2 diabetes mellitus is brought to the emergency department for chest pain and shortness of breath. Her initial blood pressure is 132/72 mm Hg and pulse is 102/min. ECG shows sinus tachycardia and a 2 mm horizontal ST segment depression in the anterior precordial leads. A chest x-ray shows bilateral patchy opacities most consistent with congestive heart failure.
She is treated with aspirin, clopidogrel, furosemide, nitroglycerin infusion, and heparin infusion. Non-invasive positive pressure ventilation is initiated. She is taken to the cardiac catheterization lab, and coronary angiography is performed which shows extensive triple vessel coronary artery disease. Pulmonary artery catheter is placed and no coronary artery intervention is performed.
The patient is transferred to the cardiac care unit. Four hours later, her blood pressure is 84/46 mm Hg and pulse is 116/min. Hemodynamic readings from the pulmonary artery catheter are shown below.

Which of the following is the most likely cause of this patient's hypotension?

Question

A 72-year-old woman with diet-controlled type 2 diabetes mellitus is brought to the emergency department for chest pain and shortness of breath.  Her initial blood pressure is 132/72 mm Hg and pulse is 102/min.  ECG shows sinus tachycardia and a 2 mm horizontal ST segment depression in the anterior precordial leads.  A chest x-ray shows bilateral patchy opacities most consistent with congestive heart failure.
She is treated with aspirin, clopidogrel, furosemide, nitroglycerin infusion, and heparin infusion.  Non-invasive positive pressure ventilation is initiated.  She is taken to the cardiac catheterization lab, and coronary angiography is performed which shows extensive triple vessel coronary artery disease.  Pulmonary artery catheter is placed and no coronary artery intervention is performed.
The patient is transferred to the cardiac care unit.  Four hours later, her blood pressure is 84/46 mm Hg and pulse is 116/min.  Hemodynamic readings from the pulmonary artery catheter are shown below.

Which of the following is the most likely cause of this patient's hypotension?

Quizplus · Accepted Answer

11ec193a_95d6_4e39_853d_8d2e4f41e012_MD0002_00 This patient's hemodynamic parameters show a low right atrial and pulmonary capillary wedge pressure. Her cardiac index is slightly reduced, and systemic vascular resistance is increased. These findings are suggestive of hypovolemia and volume depletion, possibly due to aggressive diuresis. (Choice A) Myocardial infarction with extensive myocardial damage can lead to left ventricular dysfunction and cardiogenic shock. Pulmonary artery catheterization in such patients typically reveals elevated pulmonary capillary wedge pressure, low cardiac output, and low cardiac index. (Choice B) Sepsis usually involves a compensatory increase in cardiac output in the early stages of shock. Systemic vascular resistance is typically reduced, which is useful in differentiating it from other causes of shock. (Choice C) Cardiac tamponade causes an increase in right atrial and ventricular pressures, along with a characteristic equalization of right atrial, right ventricular end diastolic, and pulmonary capillary wedge pressures. (Choice D) Patients with pulmonary embolus have elevated right atrial, right ventricular, and pulmonary artery pressures. Educational objective: Pulmonary artery catheterization provides hemodynamic data that is useful in differentiating between various causes of clinical decompensation and shock in critically ill patients. Patients with hypovolemic shock will have low right atrial and pulmonary capillary wedge pressure, along with increased systemic vascular resistance. __________

A 72-Year-Old Woman with Diet-Controlled Type 2 Diabetes Mellitus Is