Chest Pain, Nausea and Hypotension

🗒️ Question

A 70-year-old man presents to the emergency department with severe central chest pain that began 4 hours ago. The pain radiates to his left shoulder and is associated with nausea, vomiting and sweating. His past medical history includes chronic obstructive pulmonary disease (COPD), a previous myocardial infarction 3 years ago, and hypertension. He is on regular salbutamol, tiotropium, bisoprolol and ramipril.

On arrival, he is visibly pale and dyspnoeic. His heart rate is 110 bpm, blood pressure is 85/50 mmHg, respiratory rate is 24 breaths per minute and oxygen saturation is 88% on room air. A 12-lead ECG shows ST-segment elevation in leads V1-V6. Despite receiving aspirin, clopidogrel and sublingual nitrates his hypotension persists. A bedside echocardiogram shows global left ventricular hypokinesia and an ejection fraction of 25%.

Which of the following is the most likely cause of his persistent hypotension?

(A) Pulmonary oedema due to left heart failure
(B) Acute exacerbation of COPD
(C) Right ventricular infarction
(D) Cardiogenic shock
(E) Pericardial tamponade