SHM Converge Scientific Abstract ePoster Gallery-New-Onset Atrial Fibrillation Complicating the Treatment of St-Elevation Myocardial Infarction Associated With Infective Endocarditis

New-Onset Atrial Fibrillation Complicating the Treatment of St-Elevation Myocardial Infarction Associated With Infective Endocarditis

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This case describes a 44-year-old man with polysubstance and intravenous drug use who presented febrile, hypotensive, and tachycardic with malaise, dyspnea, and symptoms he thought were opioid withdrawal. Initial ECG showed new atrial fibrillation with rapid ventricular response and ST elevations in leads I, aVL, and V2–V6, consistent with acute STEMI. Laboratory studies revealed marked inflammation, severe microcytic anemia, elevated troponin, and mild lactic acidosis. Blood cultures grew Group C beta-hemolytic Streptococcus in both bottles.<br /><br />Transthoracic echocardiography demonstrated a severely reduced ejection fraction of about 25%, global hypokinesis, and a 1.7 x 1.6 cm echogenic density on the aortic valve, most consistent with vegetation, thrombus, or mass. The STEMI was attributed to coronary embolism from infective endocarditis, likely due to septic embolization from the aortic valve lesion. The new atrial fibrillation may have further complicated management.<br /><br />He was started empirically on vancomycin and cefepime, later narrowed to ceftriaxone after culture results. Rate control was attempted with IV metoprolol and then amiodarone, with limited improvement. A heparin infusion was started for myocardial infarction, but reperfusion procedures were not performed because of hemodynamic instability and lack of infection source control. Cardiac surgery judged him a poor candidate for valve replacement because of active IVDU, poor nutrition, and social barriers.<br /><br />The patient’s lactic acidosis and hyponatremia improved with fluids, and troponin levels downtrended, but he ultimately left the hospital against medical advice after 10 days. This case highlights coronary embolism as a rare but serious nonatherosclerotic cause of STEMI and illustrates the difficulty of treating STEMI caused by infective endocarditis, especially when complicated by atrial fibrillation and limited definitive source control.

Asset Subtitle

Heather Wang

Meta Tag

Author List Heather Wang, Pallavi Solanki

Category Clinical Vignettes

Concept Infective Endocarditis

Concept Coronary Embolization

Concept STEMI

Concept Septic Emboli

Concept Atrial Fibrillation

Distinguished Non-Finalist

Presenter Organization Rutgers New Jersey Medical School

Presenting Author Heather Wang

Track Adult

Keywords

infective endocarditis

coronary embolism

STEMI

aortic valve vegetation

Group C beta-hemolytic Streptococcus

intravenous drug use

atrial fibrillation

septic embolization

heparin infusion

aortic valve lesion

Infective Endocarditis

Coronary Embolization

STEMI

Septic Emboli

Atrial Fibrillation