Introduction:

Acute Heart Failure is described as rapid onset of heart failure symptoms with increased in-hospital mortality. Identification of the underlying etiology is crucial.¹ Left ventricular thrombus is a frequent complication in patients with anterior myocardial infarction. ² We present a case of a patient with acute heart failure, due to acute non-ST-elevation myocardial infarction, complicated by tachyarrhythmia and onset of a left ventricular thrombus.

Case:

A 59-year-old male presented with worsening dyspnea and chest pain. History showed a previous myocardial infarction and atrial fibrillation, but reduced medication adherence. ECG showed atrial fibrillation with negative T waves in V5 and V6. Values of troponin and N-terminal pro-brain natriuretic peptide were elevated. Acute coronary angiography showed an in-stent stenosis of the left anterior descending artery which was successfully dilated. Echocardiography revealed reduced ejection fraction (EF=15%) and left ventricular thrombus (Figure 1.). Cardio MRT verified the findings and showed a thrombus in the left atrial appendix.

The patient was treated with loop diuretic, initiated in a low dose, and escalated accordingly. Furthermore, heart failure therapy was optimized with angiotensin-converting enzyme inhibitors, beta-blocker, mineral receptor antagonist and sodium-glucose co-transporter 2 inhibitor. Due to hypotension angiotensin receptor-neprilysin inhibitor was not established. Indication for implantable cardioverter defibrillator implantation was not met since an echocardiographic control in 3 months after revascularization with optimal heart failure therapy is required¹.

The antiplatelet therapy with Acetylsalicylic acid and Clopidogrel was initiated. Because of the left ventricular and atrial thrombus and atrial fibrillation, direct oral anticoagulant therapy (DOAC) was prescribed, as a meta-analysis found no significant difference in therapeutic efficacy comparing DOACs and vitamin K antagonists ².

Conclusion:

Acute heart failure can be precipitated by a number of diseases, all of which should be promptly recognized and treated. Therapy with loop diuretics is to be started with the lowest possible dose and titrated accordingly, followed by heart failure therapy optimization.¹ The treatment of left ventricular thrombus as a complication of myocardial infarction and dilatative cardiomyopathy presents a challenge due to the fact that there are no current guideline recommendations.

Literature:

1.          McDonagh, T. A. et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur. Heart J. 42, 3599–3726 (2021).

2.          Levine, G. N. et al. Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association. Circulation 146, 205–223 (2022).

Figure 1. Echocardiography showing a left ventricular thrombus