Anyone seen an MI from septic shock?

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Specializes in Family Nurse Practitioner.

I had a guy the other week with ST depression in all leads from septic shock.. Troponin peaked in the high 20s in ICU. Young guy too.

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Specializes in Cardiology, ED/Trauma, Med-Surg, Telemetry.

I've definitely heard of this happening r/t compensation (but rarely). Just like with patients suffering from dehydration and/or renal impairment with elevated troponins, etc. Did he get enough fluid resuscitation?

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I haven't but certainly have seen varying degrees of ST depression with much much lower trop (say .03 to 1.5) that was ultimately resolved and attributed to the stress of the infection along with the persistent tachycardia that many of these pts have, so i guess it would stand to reason that if the stress was bad/prolonged enough that the ischemia could progress to the real deal.

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I can easily see a non-stentable NSTEMI due to myocardial vasospam or demand ischemia in any kind of shock.

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Likely not an MI. Acute illness, other than cardiac, can cause increase in troponin levels.

Troponin elevation in conditions other than acute coronary syndromes

ETA: The ST depression in all leads would likely not result from an NSTEMI. Rather, this is more suggestI've of systemic hypoxia or hypoperfusion.

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Specializes in Family Nurse Practitioner.

He'd had about 4 liters of fluid at this point. The ICU attending came down and ordered a fifth liter. We did another EKG and this is when the depression was seen. Then the ER doc placed a central line and we started him on pressors. The depressiom resolved later that night per an EKG done at 3am. The patient had been stented which we did not know in the ED, but they found out once he got upstairs. They were calling it a NSTEMI and recommemding he get cathed when more stable. He actually made it out of ICU after a week and was transferred to tele.

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Specializes in Family Nurse Practitioner.
I haven't but certainly have seen varying degrees of ST depression with much much lower trop (say .03 to 1.5) that was ultimately resolved and attributed to the stress of the infection along with the persistent tachycardia that many of these pts have, so i guess it would stand to reason that if the stress was bad/prolonged enough that the ischemia could progress to the real deal.

His trop coming in was like 0.567 or something. He was pretty tachy too, rate was 130s-150s. The one drawn when the st depression noted was like 0.876 or something and the next one 3 hours later was like 15. That jump seems significant. I have seen elevated troponins in septic patients but not super high like his.

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Agree. Seen this. Cardiology agreed

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Specializes in Family Nurse Practitioner.

If indeed this ST depression was solely from tissue hypoxia from sepsis and tachycardia etc, wouldn't the ST depression stick around as long as the patient was hypotensive and the lactate level high? His lactate hovered around 8 for 2-3 days before he started getting better. They were adding pressors the first night in ICU. The ST depression resolved 9-10 hours later. He was still tachycardic but not as high as he was in the ED. Remember, this patient had a history of a cardiac stent in the past and also had diabetes so two risk factors for a cardiac event.

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If indeed this ST depression was solely from tissue hypoxia from sepsis and tachycardia etc wouldn't the ST depression stick around as long as the patient was hypotensive and the lactate level high? His lactate hovered around 8 for 2-3 days before he started getting better. They were adding pressors the first night in ICU. The ST depression resolved 9-10 hours later. He was still tachycardic but not as high as he was in the ED. Remember, this patient had a history of a cardiac stent in the past and also had diabetes so two risk factors for a cardiac event.[/quote']

Global ST-depression (or elevation) doesn't really fit with an MI picture. Was his source endocarditis (you mentioned he was young, junkie?), or did he have pericarditis superimposed on something else?

For one, impaired (hypoperfused) kidneys aren't going to clear troponin, and two, for you to see the trop delta from 0.8 or whatever to 15 means his ischemia was occurring before your eyes, so if he were stentable his ECG would have changed too (depressions becoming elevations or development of Q waves).

Dude's heart just sounds like it was a little weak to begin with ("young" guy with stents, probably not walking around with a "young" EF) and his state of shock demanded more cardiac output than he could keep up with.

Now, they've started calling demand ischemia a subtype of NSTEMI, so that may be his current diagnosis but, even with limited information, that sounds more secondary to illness than anything else.

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Specializes in Family Nurse Practitioner.

Update: the patient recovered enough to go to the cath lab and they found that his existing RCA stent was 95-99% occluded so he was restented.

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