P382Acute cocaine myocarditis; cardiac arrest and beyond

Abstract

A 27-year-old gentleman presented to our hospital following a witnessed collapse as he walked out of his house. He was found to be unresponsive and had immediate bystander CPR. On arrival of the paramedics he was in ventricular fibrillation. He required 4 DC cardioversions and was administered 2 boluses of intravenous adrenaline. The patient had short periods of spontaneous circulation between cardioversions. The total length of resuscitation was 33 minutes. On arrival he was intubated and taken for immediate invasive coronary angiography which demonstrated non-obstructive coronary artery disease. His resting ECG was normal. CT head was also normal. Admission bloods were unremarkable apart from a potassium of 2.9 mmol/L. He was managed on our intensive therapy unit (ITU). During his stay on the ITU he was treated for aspiration pneumonia. An echocardiogram revealed normal LV size and systolic function with no other abnormality. Once he was extubated, he denied family history of sudden cardiac death or cardiomyopathy, any preceding viral illness or prior illicit drug use. However, he reported intermittent episodes of extreme fatigue and one episode of leg paralysis. Once stabilised (7 days after presentation) a cardiac MRI was performed. This demonstrated mild biventricular systolic impairment (LV ejection fraction 53%), mild global LVH (maximum wall thickness 14 mm; figure 1A), globally markedly increased T2 signal (figure 1C) and T1 and T2 mapping values consistent with diffuse myocardial oedema. There was also epicardial late enhancement of both the basal inferior and inferolateral segments (figure 1B). The degree of oedema was out of keeping with that expected from cardioversion and CPR. The findings of hypokalaemia, previous muscle weakness and extensive acute myocarditis would be in keeping with a toxic myocarditis due to cocaine abuse. Following the MRI scan the patient confirmed use of cocaine, which he previously had denied. Cocaine use can be associated with both myocarditis and hypokalaemia and this case illustrates both these aspects. The patient was subsequently advised to abstain from cocaine.