THE ACUTE MYOCARDIAL INFARCTION IN A 58YEAR NIGERIAN MAN AFTER CHRONIC HEART FAILURE; A DOUBLE TRAGEDY.

Chronic heart failure(CHF) and coronary heart disease shared a common aetiopathological mechanism, hence they are overlapping phases of one cardiovascular trajectory. Patients with established CHF with acute myocardial infarction (AMI) represent a high-risk subset with attendant high morbidity and mortality. The atypical clinical presentations and inconclusive investigation findings culminate in diagnostic conundrum and blunted response to reperfusion therapy.

A 58year old meat vendor known with stable CHF secondary to hypertensive heart disease presented with a week history of worsening difficulty with breathing and bilateral leg swelling with occasional dry cough, no chest pain. Examination showed patient in respiratory distress, mild bilateral pitting pedal oedema, S3 gallop. Fasting lipid profile showed dyslipidaemia with serum LDL of 105mg/dl. Troponin T of 0.4ng/ml( < 0.3). Serial electrocardiography showed sinus tachycardia with dynamic ST-T wave changes in the anterolateral leads. Echocardiography showed impaired biventricular systolic function with markedly reduced longitudinal strain (-3 to -4%) in the anterolateral LV segments. He was commenced on guidelines directed medical therapy for both acute decompensated heart failure and acute myocardial infarction and then referred for urgent coronary angiography and possible interventions.

The failing heart is vulnerable to ischemia due to reduced supply in the presence of increased demand with minimal cardiac reserve. The case highlights the need for high index of suspicion in identifying AMI as a precipitant of acute decompensated CHF as patients often present with atypical symptoms with resultant diagnostic ambiguity.