A 65-year-old man complains of 12 hours of progressive dyspnea at rest. His past history is significant for a heart attack 5 years ago. Vital signs: respiratory rate 32/min; heart rate 120/min; blood pressure 95/60 mm Hg. You see jugular venous distention and pulsations, and you hear rales two-thirds up from both bases. You also hear a loud S3 and S4 gallop, and the point of maximal impulse (PMI) is displaced laterally. He is alert and oriented, with good peripheral pulses; his skin is warm and dry. EKG shows sinus tachycardia, Q waves in II, III, and AVF, and 4 mm ST elevation in leads V1 through V4. While in the ED he suffers ventricular fibrillation and you promptly defibrillate him to a sinus tachycardia with a BP of 100/60 mm Hg. On the basis of this information, what would be this patient's in-hospital mortality?
This patient has pulmonary edema in the setting of acute myocardial infarction. He is not in cardiogenic shock as his systolic BP is greater than 90 mm Hg. This patient would be in Killip-Kimball class III, which carries 40% mortality. The mortality doubles in class IV (cardiogenic shock). Arrhythmias occurring in the first 24–48 hours of AMI are usually from transient myocardial irritability and do not necessarily impart a worse prognosis. Keep in mind that arrhythmias are the most common cause of prehospital mortality in AMI.