A 52-year-old man with sudden dyspnea, chest pain and seizures

Case report: A 52-year-old man with sudden dyspnea, chest pain, and seizures, Shijiazhuang Bethune International Peace Hospital, Yan Weimin, a 52-year-old man from the interpreter group of critical illness travellers was presented to the hospital due to confusion and chest discomfort.

When he arrived in the emergency department, he had a seizure (heart rate 134 beats/min, blood pressure 300/180mmHg).

After infusion of esmolol, the blood pressure was controlled, and benzodiazepines were used to control epilepsy.

He was given a tracheal intubation for airway protection, and was subsequently sent to our hospital for further treatment.

The chest radiograph showed infiltration around the hilar and increased vascular shadow.

B-line can be observed on ultrasound of the lungs at the bedside.

CT angiography of the head, neck, and chest showed no obvious abnormalities except for bilateral lung opacity.

No intracranial pathological changes were found on EEG and cranial MRI.

A formal cardiac ultrasound was also done.

On the first day, when hemodynamics were stable, spontaneous awakening and spontaneous breathing were restored, the patient's tracheal intubation was pulled out, and no sequelae were left.

At 8 hours, he suddenly experienced severe breathing difficulties, chest pain and facial erythema.

The blood pressure reached the highest 367/210mmHg, accompanied by bradycardia, 40 beats/min, and the oxygen saturation dropped to 60%.

An emergency tracheal intubation was implemented immediately.

A chest radiograph suggested that the pulmonary edema had increased.

The electrocardiogram showed that the ST segment was elevated in the front of the chest and the t wave in the limb leads was inverted.

Elevated troponin, cardiac catheterization revealed mild non-obstructive disease, no treatment.

Extensive investigation of secondary hypertension returned to normal.

Blood pressure was controlled with nitroglycerin infusion and intravenous labetalol.

A series of point-of-care ultrasound scans (POCUS) of the heart were performed and diuretics were used.

Over the next 6 days, he gradually transitioned to oral antihypertensive drugs, including β-blockers and calcium antagonists.

The patient was successfully offline on the 6th day and discharged from the hospital on the 9th day.

Question 1: Based on the clinical manifestations and bedside echocardiographic performance of Video 1 and Video 2, the most likely explanation is the failure of the patient's extubation on day 1? Question 2: Figures 1 and 2 were obtained on day 1, Figure 3 And Figure 4 was obtained on the 4th day.

What are the possible explanations for the results in Figures 3 and 4? Answer 1: The patient suffered from hypertensive emergency, poor blood pressure control, and secondary acute pulmonary edema, leading to acute hypoxic respiratory failure.

Ultrasound images 1 and 2 provide qualitative evidence confirming left ventricular hypertrophy.

Figure 5 makes a quantitative assessment.

As shown in Figure 6, relative wall thickness (RWT) and left ventricular mass index are the two parameters of ventricular hypertrophy (centrality vs.
eccentricity).

Left ventricular filling pressure (LVFP) can be estimated by the ratio of the early-circular diastolic velocity induced by pulsed tissue Doppler to the early-circular diastolic velocity.

A ratio >14 indicates high LVFP, and a ratio <8 indicates normal filling pressure.

In patients with diastolic dysfunction, the ratio of the mitral valve flow rate between the early and late ventricular filling velocity (E/A) allows classification of the filling pattern.

E/A ratio>0.
8-2.
0 indicates grade I or grade II diastolic insufficiency, depending on early diastolic velocity, tricuspid regurgitation and left atrial volume, while E/A ratio>2.
0 is diagnosed as grade III restrictive diastole Functional insufficiency.

Answer 2: Figures 1 and 3 show that the E/A value of diastolic function assessed by POCUS on the first day dropped from 2.
2 on the first day to 1.
56 on the fourth day.

Figure 4 shows that the early diastolic ratio is 12, which drops to the gray zone (early diastolic ratio 8-14), which means the critically high value of LVFP.

However, compared to the early diastolic ratio of 20.
3 on the first day, it was significantly improved (Figure 2).

This improvement is likely to be the result of diuresis and decreased pre- and post-load.

Discussion Hypertension is one of the causes of geometric deformation of the heart structure, leading to congestive heart failure.

Controlling blood pressure has a significant clinical effect, preventing malignant events such as myocardial ischemia, stroke, left ventricular hypertrophy and heart failure.

After the ventilator was released on the first day, the patient was interviewed in detail.

He reported that he was diagnosed with high blood pressure a few years ago and has not been monitored and treated due to non-compliance with the doctor's advice.


The measurement of a formal echocardiographic study conducted on the first day showed that the left ventricular ejection fraction was reduced to 45%, the early diastolic ratio was significantly increased to 20.
3, and the E/A ratio was 2.
2, suggesting the presence of grade III diastolic dysfunction , And the mode is limited.

There is also moderate mitral regurgitation, but the valve structure is normal.

It should be noted that we only implemented point-of-care ultrasound scan (POCUS) on the 4th day after the patient received diuretics, and clinical improvement has been confirmed.

Our evaluation has confirmed a significant improvement after the application of diuretics, because E/A decreased from 2.
2 to 1.
56, and the early diastolic ratio decreased from 20.
3 to 12 (Figure 3, Figure 4).

The relative wall thickness (RWT) is 0.
5 (Figure 5), but the left ventricular mass is 252g, and the left ventricular mass index is 126g/㎡.

The left atrium volume index was 40ml/㎡, and only a small amount of tricuspid regurgitation was observed.


As previously reported in the literature, long-term uncontrolled high blood pressure can lead to structural remodeling of the heart, thereby impairing the ability of the ventricles to accept and contain blood.

Left ventricular hypertrophy, that is, an increase in ventricular mass index (>115g/㎡) and relative wall thickness (RWT) (>0.
42) (Figure 5), has been confirmed to have an increased risk of dying from a cardiac event.

The existence of pure centripetal remodeling (defined as an increase in RWT, >0.
42, while the left ventricular mass index does not increase) can also lead to pathological events.

RWT is calculated by measuring the left ventricular posterior wall thickness (PWT) and left ventricular diameter (LVID) at the end of diastole and using the following formula: RWT 1⁄4 2 PWT=LVID.

 The left ventricular mass and the left ventricular mass index are calculated using the ventricular septum (IVS), left ventricular diameter (LVID) and PWT formulas: the recently updated guidelines outline the diagnostic criteria for diastolic heart failure, as shown in Figure 7.

In patients with normal left ventricular ejection fraction, four parameters were identified as key parameters in the diagnostic method.

These include left atrial volume index> 34 mL/m2, tricuspid regurgitation velocity> 2.
8 m/s, early diastolic velocity of the mitral annulus (e') <7 cm/s or lateral e'<10 cm/s , The average early diastolic ratio>14.

More than half of the patients can be diagnosed as diastolic dysfunction.

By definition, patients with systolic insufficiency (ejection fraction <50%) also have diastolic insufficiency.

For the latter, the focus of further analysis is LVFP (early diastolic rate) and the classification of diastolic insufficiency (E/A).

In the case of critical illness, the assessment of diastolic function is challenging; however, it can have clinical utility in many situations.

For example, there is increasing evidence that diastolic function parameters of patients with sepsis are related to prognosis.

Recently, Greenstein and Mayo proposed a simpler method of assessing diastolic function in critically ill patients (Figure 8).

This method recognizes that in this special patient population, it is difficult to calculate the left atrial volume and measure the tricuspid regurgitation jet with POCUS, and emphasizes the measurement of e'and early diastolic rate.

In our case, the serial assessment of LVFP provides an additional parameter to assess the response of patients with cardiogenic pulmonary edema to diuretic therapy.

We recognize that the diagnosis of this case can only be made on a clinical basis, and treatment adjustments can be determined by using clinical parameters.

However, with more and more studies on the use of advanced echocardiographic parameters in critical care settings, it is likely that they will increasingly be incorporated into the diagnosis and treatment of these patients.

The combination of clinical and ultrasound evaluation not only helps to guide the treatment of heart failure, but also helps to wean patients with mechanical ventilation.

The use of point-of-care ultrasound scanning (POCUS) to continuously monitor the early diastolic ratio can assess diastolic function and help critical care doctors identify patients who are most likely to have difficulty weaning.

It has been found that a high E/A value can predict the occurrence of congestive heart failure and increase the mortality of patients.

The subsequent point-of-care ultrasound scan (POCUS) showed that the patient's E/A value and the early diastolic ratio improved, which can strengthen our treatment plan and provide confidence in offline experiments.

It has been proven that rapid and appropriate antihypertensive treatment is beneficial and can protect the left ventricle from structural changes.

Response 1.
Long-term uncontrolled hypertension can adversely affect the structure and function of the heart, and can lead to ventricular remodeling and centripetal or eccentric hypertrophy.

2.
Hypertension is a common cause of congestive heart failure.
Treatment of hypertension can prevent many harmful events, including stroke, myocardial infarction, heart failure and renal failure.

3.
POCUS (real-time ultrasound scan) can help identify changes in left ventricular anatomy, and can also identify diastolic failure caused by uncontrolled hypertension.

4.
Patients with diastolic dysfunction are more likely to develop respiratory failure after weaning.

5.
Continuous diastolic function monitoring implemented by bedside cardiac ultrasound assessment can help critical care specialists better treat heart failure and prevent failure after weaning.

Learning and instilling advanced ultrasound technology in clinical practice is very beneficial to clinicians.

In fact, the Advanced Intensive Care Echocardiography Committee composed of the National Echocardiography Committee has now been established, which is an interesting place for clinicians to test their knowledge and verify their expertise.

Source: Critical Care Medicine-END-Please long press the picture below to identify the QR code and pay attention to dopamine.
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