Successful staged Percutaneous Coronary Intervention (PCI) in a patient with cardiogenic shock and triple vessel disease

Maha Lakshmi^1*, Subathra Devi M², Arockia Suba³

¹Nursing Superintendent, Kauvery hospital, Cantonment, Trichy, Tamil Nadu

²Nurse Educator, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

³Nurse In-Charge, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

*Correspondence

Abstract

This case describes a patient known to have diabetes and hypertension who presented with chest pain and sudden cardiac arrest at the emergency entrance. Immediate CPR and defibrillation were performed and return of spontaneous circulation was achieved. ECG confirmed Acute Anterior Wall Myocardial Infarction (AWMI) with cardiogenic shock. Coronary angiography revealed triple vessel disease with 100% occlusion of the proximal LAD. The patient underwent successful primary PCI followed by staged PCI, restoring TIMI III flow with good clinical outcome.

Key words: Acute Anterior Wall Myocardial Infarction (AWMI); Left Anterior Descending (LAD) artery; Percutaneous coronary intervention (PCI).

Introduction

Acute Anterior Wall Myocardial Infarction is a life-threatening cardiac emergency commonly caused by occlusion of the Left Anterior Descending (LAD) artery. Patients with risk factors such as diabetes mellitus and hypertension have a higher risk of severe coronary artery disease and cardiogenic shock. Early recognition, immediate resuscitation, and timely percutaneous coronary intervention (PCI) are crucial in improving survival and reducing complications in such high-risk patients.

Case presentation

A 73-year-old male was found collapsed within the hospital premises, with no attendants available at the time. On arrival at the emergency room, the patient was gasping and unresponsive, with a Glasgow Coma Scale (GCS) of E₁ V₁ M₁. His airway was not patent, with pooling of saliva noted, and no carotid pulse was felt. Immediate cardiopulmonary resuscitation (CPR) was initiated, and a definitive airway was secured. Rhythm analysis revealed a shockable rhythm, and defibrillation was administered along with effective CPR. Return of Spontaneous Circulation (ROSC) was achieved after resuscitation. Subsequently, the patient developed recurrent ventricular tachycardia, which was managed with antiarrhythmic medications. ECG revealed ST-elevation myocardial infarction (STEMI), and the case was discussed with the cardiologist. The patient was then shifted for further cardiac management.

Cardiac enzymes were elevated, and GRBS was 379 mg/dL. Echocardiography showed moderate left ventricular dysfunction with an ejection fraction of 35–40%. Serum creatinine was 1.74 mg/dL, suggestive of acute kidney injury. Coronary angiography (30/06/2025) revealed proximal LAD 100% occlusion, Ramus Intermedius 90% lesion, proximal RCA 90% lesion, mid RCA 70–80% stenosis, and a non-dominant normal LCx. The final diagnosis was Triple Vessel Disease.

At the time of shifting, the patient’s GCS had improved to E₄V_TM₆, pupils were equal and reactive to light, and he was moving all four limbs. His heart rate was 106 beats per minute, blood pressure was 140/80 mmHg, and oxygen saturation was 99% on 50% FiO₂. He was on SIMV mode ventilation with PEEP. He was receiving inotropic support with adrenaline at 5 mL/hr and noradrenaline at 20 mL/hr.

The patient underwent primary PCI on 30/06/2025 to the mid LAD, where a Bio matrix 2.75 × 37 mm drug-eluting stent (DES) was deployed after predilatation with a Maverick 2.0 × 9 mm balloon. TIMI III flow was restored with no residual stenosis. A staged PCI was performed on 03/07/2025 targeting the proximal to mid RCA and proximal Ramus lesions. Predilatation was done using a Maverick 2.0 × 9 mm balloon, followed by dilation with an NC Quantum Apex 3.25 × 12 mm balloon, and drug-eluting stents were successfully deployed with optimal expansion.

Relevant Clinical Findings

Social History: He does not have any history of cigarette smoking and alcohol addiction.

Allergies: No known medicine or environmental allergies.

Past Medical History: Known case of DM, HTN on treatment.

Past Surgical history: No past surgical history.

Physical Examinations

Patient gasping.

GCS	E1 V1 M1
Airway	Not patent, pooling of saliva
Circulation	Carotid pulse not felt
Exposure	No abnormalities noted

Relevant Investigation

CBC
Hemoglobin	11.1 g/dl
Hematocrit	26 %
Total RBC Count	3.67 10^9/cumm
Total WBC Count	12160 Cells/cumm
Lymphocyte	26.0 %
Monocyte	5.4 %
Eosinophil	0.7 %
Platelet Count	138000 cells/µl
Neutrophil	67.6 %
LFT
ALT (SGPT)	124.7 U/L
AST (SGOT)	162.7 U/L
Alkaline Phosphatase	57.9 U/L
GGT	41 U/L
Total Bilirubin	0.56 mg/dL
Direct Bilirubin	0.31 mg/dL
Indirect Bilirubin	0.25 mg/dL
Total Protein	6.53 g/dl
Albumin	3.64 g/dl
Globulin	2.89 g/dl
A/G Ratio	1.26
(RFT)
Urea Serum	25.68 mg/dL
Creatinine	1.57 mg/dL
Electrolytes & Blood Gas
Sodium (Na+)	143 / 144 mmol/L
Potassium (K+)	3.11 / 3.3 mmol/L
Chloride	104 / 110 mEq/L
Bicarbonate (HCO3)	12.5 / 17 mmol/L
Other values
pH Blood	7.20
Lactate (Lac)	10.9 mmol/L
Calcium (CA++)	0.72 mmol/L
Glucose	254 mg/dL
Glucose In Glucometer POCT	132 mg/dL
INR	1.18
Test (APTT)	27.1 Seconds
Test (PT)	13.5 Seconds
Troponin I (Quantitative)	0.03 ng/mL
Control (PT)	11.4 Seconds
Control (APTT)	26.1 Seconds
PCO2	32 mm Hg
Chloride Blood	110 mEq/L
K +	3.3 mmol/L
O2Sat	79.7 %
PO2	54 mm Hg
HCO3(c)	12.5 mmol/L
BE(B)	-14.4 mm Hg
NA+	143 mmol/L
Packed Cell Volume (PCV)	34.9 %

Diagnosis

Acute Anterior Wall Myocardial Infarction (AWMI).
Cardiogenic Shock – Recovered.
Triple Vessel Coronary Artery Disease.
Type 2 Diabetes Mellitus.
Systemic Hypertension.
Acute Kidney Injury – Resolved.

Management

Procedures and Interventions.

Primary PCI (30/06/2025)

Target Vessel	Mid LAD
Stent Used	Biomatrix 2.75 × 37 mm (DES)
Procedure	Predilation with Maverick 2.0 × 9 mm balloon, stent deployed successfully with optimal result.
Outcome	TIMI III flow restored, no residual stenosis.

Staged PCI (03/07/2025)

Target Vessels	Proximal to Mid RCA and Proximal Ramus
Stents Used	DES (Drug-Eluting Stents)
Procedure	Predilation with Maverick 2.0 × 9 mm balloon; RCA lesion dilated with NC Quantum Apex 3.25 × 12 mm balloon, stent deployed with optimal expansion.

Out Come

Successful PTCA with TIMI III flow in all treated vessels.
Post-Procedural Course.
Extubated and maintained on oxygen support.
Diuretics, IV antibiotics, anticoagulants, statins, and dual antiplatelet therapy continued.
Gradual hemodynamic improvement with resolution of shock.
AKI improved with supportive care.
No further cardiac events during hospital stay.
Medications on Discharge.
The patient was discharged in stable condition.

Nursing Management

Airway & Breathing

Maintain patent airway.
Suction secretions as needed.
Monitor ventilator settings (SIMV, PEEP, TV, PS).
Monitor SpO₂ continuously.
Assess respiratory distress.

Circulation

Continuous ECG monitoring.
Monitor heart rate and rhythm.
Check blood pressure frequently.
Observe arrhythmias (VT, VF).
Maintain IV access.

Post–Cardiac Arrest Care

Monitor neurological status (GCS, pupils).
Maintain adequate oxygenation.
Monitor temperature.
Prevent aspiration.

Inotrope Management

Monitor infusion of adrenaline and noradrenaline.
Check blood pressure closely.
Watch for signs of extravasation.
Titrate drugs as per order.

Fluid & Renal Monitoring

Strict intake and output charting.
Monitor urine output hourly.
Assess for fluid overload.

Medication Administration

Administer antiplatelets, anticoagulants, statins as prescribed.
Monitor for drug side effects.
Ensure timely medication administration.

Puncture Site / Procedure Care (if PCI done)

Check for bleeding or hematoma.
Monitor distal pulses.
Maintain bed rest as advised.

Prevention of Complications

DVT prophylaxis.
Pressure sore prevention.
Infection control practices.

Psychological & Family Support

Provide comfort and support for the attender.
Update family about patient condition.

Discharge medications

Discharge Advice.
Diet: 1500 kcal low-fat diabetic diet.
Fluid Restriction: 15 L/day.

Ticagrelor 90 mg	BD
Ecosprin 75 mg	OD
Atorvastatin 40 mg	OD
Pantoprazole 40 mg	BF - OD
Concor 2.5 mg	HS
Ivabradine 5 mg	OD
Furosemide 40 mg	BD
Ativan 1 mg	HS
Febuxostat 40 mg	OD
Glimepiride + Metformin 05 mg/500 mg	BD - BF

Emergency symptoms: Chest pain, breathlessness, syncope → Report immediately.

Discussion

This case highlights a complex scenario of acute myocardial infarction with cardiogenic shock in a diabetic elderly male with triple vessel disease early recognition, prompt resuscitation, and staged PCI led to recovery and favorable outcome the case emphasizes the significance of timely intervention and individualized staged revascularization strategy in high-risk cardiac patient.

Conclusion

This case highlights the successful resuscitation and management of who suffered sudden cardiac arrest secondary to ST-elevation Myocardial Infarction (STEMI) early recognition, immediate high-quality CPR, prompt defibrillation, and rapid stabilization played a crucial role in achieving return of spontaneous circulation timely cardiology intervention and appropriate critical care management, including ventilator and inotropic support, contributed to hemodynamic stabilization and neurological recovery.

The case emphasizes the importance of rapid emergency response, continuous cardiac monitoring, multidisciplinary coordination, and comprehensive nursing care in improving survival and clinical outcomes in high-risk cardiac patients.

Successful staged Percutaneous Coronary Intervention (PCI) in a patient with cardiogenic shock and triple vessel disease

Successful staged Percutaneous Coronary Intervention (PCI) in a patient with cardiogenic shock and triple vessel disease

Maha Lakshmi1*, Subathra Devi M2, Arockia Suba3

Nightingale Journals

Maha Lakshmi^1*, Subathra Devi M², Arockia Suba³