Case 3/2017-A 47-Year-Old Female with Refractory Heart Failure and Embolic Acute Myocardial Infarction

The patient was a 47-year-old white single female referred for medical treatment to the Instituto do Coracao, born and coming from the state of Sao Paulo, with four children, unemployed, but reporting having worked in coffee farming in inner Minas Gerais state. At the time of her first medical consultation (September 25, 2015), she reported dyspnea on minimal exertion, orthopnea and anasarca, which had started 2 months earlier. She denied angina pectoris, previous myocardial infarction and syncope. She knew she had systemic arterial hypertension and diabetes mellitus, and was being treated at a basic health unit. She used to smoke (20 packs/year), but quit the habit 2 months before. She denied consuming alcoholic beverages and illicit drugs, as well as a family history of cardiovascular disease. She was on metformin (2550 mg/day), furosemide (80 mg/day), carvedilol (12.5 mg/day), and losartan (50 mg/day). On her first medical consultation, her physical exam showed regular general condition and dyspnea in the horizontal position. Her blood pressure was 100/70 mmHg, and heart rate, 102 bpm. Her pulmonary auscultation revealed no respiratory sound on the base of the right lung and no rales. Her cardiac auscultation showed regular gallop rhythm, due to the presence of the third heart sound, and no murmur. Her abdomen was globose, tense, painless, with signs of huge ascites. Her extremities were cold and edematous (++/4+), with symmetrical pulses. The electrocardiogram on the medical consultation showed sinus rhythm, heart rate of 97 bpm, left atrial overload and indirect signs of right atrial overload (Penaloza-Tranchesi sign), low voltage of the QRS complexes in the frontal plane and no progression of the R wave in V-1 to V-4 (probable electrically inactive area in the anterior wall), and diffuse changes of ventricular repolarization (Figure 1). Her chest X-ray showed bilateral veiling of costophrenic sinus, with pleural effusion up to half of the right hemithorax, normal aorta and global heart enlargement (++++/4+) (Figure 2).