ACUTE HYPOXEMIC RESPIRATORY FAILURE WITH SEVERE HYPERLACTATEMIA AND MIXED ACID–BASE DISORDER IN A PATIENT WITH PREVIOUS MYOCARDIAL INFARCTION: A CASE REPORT
Keywords:
Acute hypoxemic respiratory failure, Hyperlactatemia, Mixed acid–base disorder, Acute heart failure, Myocardial infarctionAbstract
Introduction: Acute heart failure (AHF) presenting as acute pulmonary edema is a leading cause of acute hypoxemic respiratory failure (AHRF). Elevated lactate identifies organ injury and a worse prognosis in AHF even without overt hypoperfusion, and lactate combined with acidemia strongly modifies mortality in cardiogenic shock; when severe hyperlactatemia coexists with a primary respiratory alkalosis, a near-normal pH may conceal the true metabolic severity.1–3
Case illustration: A 48-year-old man with a previous ST-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) and a prior episode of AHF presented with dyspnea since the previous night, respiratory rate 41 breaths/min, SpO2 78% on room air (87% on a non-rebreathing mask), blood pressure 148/103 mmHg, heart rate 120 beats/min, warm extremities and bilateral crackles with wheezing. Arterial blood gas (reported FiO2 0.81) showed pH 7.35, PaCO2 21 mmHg, PaO2 52 mmHg, HCO3− 11.8 mmol/L, base excess −14 mmol/L and lactate 11.20 mmol/L; PaCO2 below the Winter's range (23.7–27.7 mmHg) indicated a concurrent primary respiratory alkalosis. High-sensitivity troponin I was 65.2 pg/mL (≈1.7 × upper reference limit), creatinine 1.84 mg/dL, potassium 2.8 mmol/L and glucose 300 mg/dL. Despite nitroglycerin, furosemide and mask oxygen he required intubation, after which high respiratory drive (total rate 43 breaths/min; tidal volume ≈10.6 mL/kg predicted body weight), severe hypoxemia (SpO2 93% on FiO2 0.85) and a fall in blood pressure to 101/55 mmHg were documented.4–6
Discussion: The ≈13% reduction in arterial oxygen content could not by itself explain a lactate of 11.2 mmol/L, implying superimposed normotensive low-output hypoperfusion, catecholamine-driven aerobic glycolysis—mirrored by hypokalemia and hyperglycemia—alkalosis-enhanced glycolysis, increased work of breathing and reduced clearance. The near-normal pH concealed a profound base deficit, a metabolic–hemodynamic discordance poorly captured by blood pressure-based staging, while vigorous post-intubation effort carried a risk of patient self-inflicted lung injury.7–10
Conclusion: In AHF complicated by AHRF, severe hyperlactatemia with a mixed acid–base disorder is a high-risk phenotype even when blood pressure is preserved. Systematic acid–base analysis, serial lactate, early echocardiography and lung ultrasound, timely evaluation for acute coronary syndrome, potassium repletion before or with insulin and diuretics, and lung-protective ventilation that controls respiratory drive are essential.11,12
References
Masip J, Peacock WF, Arrigo M, Rossello X, Platz E, Cullen L, et al. Acute heart failure in the 2021 ESC Heart Failure Guidelines: a scientific statement from the Association for Acute CardioVascular Care (ACVC) of the European Society of Cardiology. Eur Heart J Acute Cardiovasc Care. 2022;11(2):173–85. https://doi.org/10.1093/ehjacc/zuab122
Zymliński R, Biegus J, Sokolski M, Siwołowski P, Nawrocka-Millward S, Todd J, et al. Increased blood lactate is prevalent and identifies poor prognosis in patients with acute heart failure without overt peripheral hypoperfusion. Eur J Heart Fail. 2018;20(6):1011–8. https://doi.org/10.1002/ejhf.1156
Jentzer JC, Schrage B, Patel PC, Kashani KB, Barsness GW, Holmes DR, et al. Association between the acidemia, lactic acidosis, and shock severity with outcomes in patients with cardiogenic shock. J Am Heart Assoc. 2022;11(9):e024932. https://doi.org/10.1161/JAHA.121.024932
Riley DS, Barber MS, Kienle GS, Aronson JK, von Schoen-Angerer T, Tugwell P, et al. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol. 2017;89:218–35. https://doi.org/10.1016/j.jclinepi.2017.04.026
Adrogué HJ, Gennari FJ, Galla JH, Madias NE. Assessing acid-base disorders. Kidney Int. 2009;76(12):1239–47. https://doi.org/10.1038/ki.2009.359
Acute Respiratory Distress Syndrome Network; Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301–8. https://doi.org/10.1056/NEJM200005043421801
Kraut JA, Madias NE. Lactic acidosis. N Engl J Med. 2014;371(24):2309–19. https://doi.org/10.1056/NEJMra1309483
Garcia-Alvarez M, Marik P, Bellomo R. Sepsis-associated hyperlactatemia. Crit Care. 2014;18(5):503. https://doi.org/10.1186/s13054-014-0503-3
Naidu SS, Baran DA, Jentzer JC, Hollenberg SM, van Diepen S, Basir MB, et al. SCAI SHOCK stage classification expert consensus update: a review and incorporation of validation studies. J Soc Cardiovasc Angiogr Interv. 2022;1(1):100008. https://doi.org/10.1016/j.jscai.2021.100008
Brochard L, Slutsky A, Pesenti A. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Am J Respir Crit Care Med. 2017;195(4):438–42. https://doi.org/10.1164/rccm.201605-1081CP
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023;44(37):3627–39. https://doi.org/10.1093/eurheartj/ehad195
Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720–826. https://doi.org/10.1093/eurheartj/ehad191
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599–726. https://doi.org/10.1093/eurheartj/ehab368
Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). Circulation. 2018;138(20):e618–51. https://doi.org/10.1161/CIR.0000000000000617
Matthay MA, Arabi Y, Arroliga AC, Bernard G, Bersten AD, Brochard LJ, et al. A new global definition of acute respiratory distress syndrome. Am J Respir Crit Care Med. 2024;209(1):37–47. https://doi.org/10.1164/rccm.202303-0558WS
Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. 2023;49(7):727–59. https://doi.org/10.1007/s00134-023-07050-7
Maw AM, Hassanin A, Ho PM, McInnes MDF, Moss A, Juarez-Colunga E, et al. Diagnostic accuracy of point-of-care lung ultrasonography and chest radiography in adults with symptoms suggestive of acute decompensated heart failure: a systematic review and meta-analysis. JAMA Netw Open. 2019;2(3):e190703. https://doi.org/10.1001/jamanetworkopen.2019.0703
Harjola VP, Lassus J, Sionis A, Køber L, Tarvasmäki T, Spinar J, et al. Clinical picture and risk prediction of short-term mortality in cardiogenic shock. Eur J Heart Fail. 2015;17(5):501–9. https://doi.org/10.1002/ejhf.260
Marbach JA, Di Santo P, Kapur NK, Thayer KL, Simard T, Jung RG, et al. Lactate clearance as a surrogate for mortality in cardiogenic shock: insights from the DOREMI trial. J Am Heart Assoc. 2022;11(6):e023322. https://doi.org/10.1161/JAHA.121.023322
Gajewski P, Wilk MM, Aleksandrowicz K, Ponikowska B, Zymliński R. Lactate in heart failure. Int J Mol Sci. 2025;26(14):6810. https://doi.org/10.3390/ijms26146810
Andersen LW, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc. 2013;88(10):1127–40. https://doi.org/10.1016/j.mayocp.2013.06.012
Park JJ, Choi DJ, Yoon CH, Oh IY, Lee JH, Ahn S, et al. The prognostic value of arterial blood gas analysis in high-risk acute heart failure patients: an analysis of the Korean Heart Failure (KorHF) registry. Eur J Heart Fail. 2015;17(6):601–11. https://doi.org/10.1002/ejhf.276
Palmer BF, Clegg DJ. Mixed acid-base disturbances: core curriculum 2025. Am J Kidney Dis. 2025;86(3):372–82. https://doi.org/10.1053/j.ajkd.2025.04.014
Achanti A, Szerlip HM. Acid-base disorders in the critically ill patient. Clin J Am Soc Nephrol. 2023;18(1):102–12. https://doi.org/10.2215/CJN.04500422
Baran DA, Grines CL, Bailey S, Burkhoff D, Hall SA, Henry TD, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock. Catheter Cardiovasc Interv. 2019;94(1):29–37. https://doi.org/10.1002/ccd.28329
Kapur NK, Kanwar M, Sinha SS, Thayer KL, Garan AR, Hernandez-Montfort J, et al. Criteria for defining stages of cardiogenic shock severity. J Am Coll Cardiol. 2022;80(3):185–98. https://doi.org/10.1016/j.jacc.2022.04.049
Jentzer JC, van Diepen S, Barsness GW, Henry TD, Menon V, Rihal CS, et al. Cardiogenic shock classification to predict mortality in the cardiac intensive care unit. J Am Coll Cardiol. 2019;74(17):2117–28. https://doi.org/10.1016/j.jacc.2019.07.077
Berbenetz N, Wang Y, Brown J, Godfrey C, Ahmad M, Vital FM, et al. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev. 2019;4(4):CD005351. https://doi.org/10.1002/14651858.CD005351.pub4
Masip J, Peacock WF, Price S, Cullen L, Martin-Sanchez FJ, Seferovic P, et al. Indications and practical approach to non-invasive ventilation in acute heart failure. Eur Heart J. 2018;39(1):17–25. https://doi.org/10.1093/eurheartj/ehx580
Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, et al. Intubation practices and adverse peri-intubation events in critically ill patients from 29 countries. JAMA. 2021;325(12):1164–72. https://doi.org/10.1001/jama.2021.1727
Hillier TA, Abbott RD, Barrett EJ. Hyponatremia: evaluating the correction factor for hyperglycemia. Am J Med. 1999;106(4):399–403. https://doi.org/10.1016/S0002-9343(99)00055-8
Vandenberk B, Vandael E, Robyns T, Vandenberghe J, Garweg C, Foulon V, et al. Which QT correction formulae to use for QT monitoring? J Am Heart Assoc. 2016;5(6):e003264. https://doi.org/10.1161/JAHA.116.003264
Luo S, Michler K, Johnston P, Macfarlane PW. A comparison of commonly used QT correction formulae: the effect of heart rate on the QTc of normal ECGs. J Electrocardiol. 2004;37 Suppl:81–90. https://doi.org/10.1016/j.jelectrocard.2004.08.030
Mullens W, Damman K, Harjola VP, Mebazaa A, Brunner-La Rocca HP, Martens P, et al. The use of diuretics in heart failure with congestion – a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2019;21(2):137–55. https://doi.org/10.1002/ejhf.1369
Pivetta E, Goffi A, Nazerian P, Castagno D, Tozzetti C, Tizzani P, et al. Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial. Eur J Heart Fail. 2019;21(6):754–66. https://doi.org/10.1002/ejhf.1379
Long B, Brady WJ, Gottlieb M. Emergency medicine updates: sympathetic crashing acute pulmonary edema. Am J Emerg Med. 2025;90:35–40. https://doi.org/10.1016/j.ajem.2024.12.061
Pramudyo M, Kamarullah W, Pranata R, Prameswari HS, Iqbal M, Dewi TI, et al. Low-dose versus high-dose intravenous nitroglycerin in the treatment of sympathetic crashing acute pulmonary oedema: a systematic review and meta-analysis focusing on efficacy, safety and outcomes. BMJ Open. 2025;15(6):e099142. https://doi.org/10.1136/bmjopen-2025-099142
Esdaile H, Khan S, Mayet J, Oliver N, Reddy M, Shah ASV. The association between the stress hyperglycaemia ratio and mortality in cardiovascular disease: a meta-analysis and systematic review. Cardiovasc Diabetol. 2024;23(1):412. https://doi.org/10.1186/s12933-024-02454-1
Carteaux G, Parfait M, Combet M, Haudebourg AF, Tuffet S, Mekontso Dessap A. Patient-self inflicted lung injury: a practical review. J Clin Med. 2021;10(12):2738. https://doi.org/10.3390/jcm10122738
Didwania A, Miller J, Kassel D, Jackson EV, Chernow B. Effect of intravenous lactated Ringer's solution infusion on the circulating lactate concentration: Part 3. Results of a prospective, randomized, double-blind, placebo-controlled trial. Crit Care Med. 1997;25(11):1851–4. https://doi.org/10.1097/00003246-199711000-00024
Mullens W, Damman K, Testani JM, Martens P, Mueller C, Lassus J, et al. Evaluation of kidney function throughout the heart failure trajectory – a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2020;22(4):584–603. https://doi.org/10.1002/ejhf.1697
Katz MA. Hyperglycemia-induced hyponatremia – calculation of expected serum sodium depression. N Engl J Med. 1973;289(16):843–4. https://doi.org/10.1056/NEJM197310182891607
Kildegaard H, Brabrand M, Forberg JL, Platonov P, Lassen AT, Ekelund U. Prevalence and prognostic value of electrocardiographic abnormalities in hypokalemia: a multicenter cohort study. J Intern Med. 2024;295(4):544–56. https://doi.org/10.1111/joim.13757
Gurney JW, Goodman LR. Pulmonary edema localized in the right upper lobe accompanying mitral regurgitation. Radiology. 1989;171(2):397–9. https://doi.org/10.1148/radiology.171.2.2704804
Nishimura Y, Komatsu J, Sugane H, Hosoda H, Imai R, Nakaoka Y, et al. Unilateral pulmonary edema in patients with acute mitral regurgitation caused by chordal rupture. Circ Rep. 2022;4(12):571–8. https://doi.org/10.1253/circrep.CR-22-0090
Russotto V, Tassistro E, Myatra SN, Parotto M, Antolini L, Bauer P, et al. Peri-intubation cardiovascular collapse in critically ill patients: insights from the INTUBE study. Am J Respir Crit Care Med. 2022;206(4):449–58. https://doi.org/10.1164/rccm.202111-2575OC
Ko DR, Beom J, Lee HS, You JS, Chung HS, Chung SP. Benefits of high-flow nasal cannula therapy for acute pulmonary edema in patients with heart failure in the emergency department: a prospective multi-center randomized controlled trial. J Clin Med. 2020;9(6):1937. https://doi.org/10.3390/jcm9061937
Felker GM, Ellison DH, Mullens W, Cox ZL, Testani JM. Diuretic therapy for patients with heart failure: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(10):1178–95. https://doi.org/10.1016/j.jacc.2019.12.059
Núñez J, Bayés-Genís A, Zannad F, Rossignol P, Núñez E, Bodí V, et al. Long-term potassium monitoring and dynamics in heart failure and risk of mortality. Circulation. 2018;137(13):1320–30. https://doi.org/10.1161/CIRCULATIONAHA.117.030576
Zitek T, Skaggs ZD, Rahbar A, Patel J, Khan M. Does intravenous lactated Ringer's solution raise serum lactate? J Emerg Med. 2018;55(3):313–8. https://doi.org/10.1016/j.jemermed.2018.05.031
Jøns C, Zheng C, Winsløw UCG, Danielsen EM, Sakthivel T, Frandsen EA, et al. Increasing the potassium level in patients at high risk for ventricular arrhythmias. N Engl J Med. 2025;393(20):1979–89. https://doi.org/10.1056/NEJMoa2509542
Colombo MG, Kirchberger I, Amann U, Dinser L, Meisinger C. Association of serum potassium concentration with mortality and ventricular arrhythmias in patients with acute myocardial infarction: a systematic review and meta-analysis. Eur J Prev Cardiol. 2018;25(6):576–95. https://doi.org/10.1177/2047487318759694
Ronco C, Haapio M, House AA, Anavekar N, Bellomo R. Cardiorenal syndrome. J Am Coll Cardiol. 2008;52(19):1527–39. https://doi.org/10.1016/j.jacc.2008.07.051
Handagala R, Ralapanawa U, Jayalath T. Unilateral pulmonary edema: a case report and review of the literature. J Med Case Rep. 2018;12(1):219. https://doi.org/10.1186/s13256-018-1739-3
Song G, Liu X, Lu Z, Guan J, Chen X, Li Y, et al. Relationship between stress hyperglycaemic ratio (SHR) and critical illness: a systematic review. Cardiovasc Diabetol. 2025;24(1):188. https://doi.org/10.1186/s12933-025-02751-3
De Backer D, Creteur J, Zhang H, Norrenberg M, Vincent JL. Lactate production by the lungs in acute lung injury. Am J Respir Crit Care Med. 1997;156(4):1099–104. https://doi.org/10.1164/ajrccm.156.4.9701048
DeFronzo R, Fleming GA, Chen K, Bicsak TA. Metformin-associated lactic acidosis: current perspectives on causes and risk. Metabolism. 2016;65(2):20–9. https://doi.org/10.1016/j.metabol.2015.10.014
Peters AL, Buschur EO, Buse JB, Cohan P, Diner JC, Hirsch IB. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015;38(9):1687–93. https://doi.org/10.2337/dc15-0843
Lorenzi-Filho G, Azevedo ER, Parker JD, Bradley TD. Relationship of carbon dioxide tension in arterial blood to pulmonary wedge pressure in heart failure. Eur Respir J. 2002;19(1):37–40. https://doi.org/10.1183/09031936.02.00214502
DeFilippis AP, Chapman AR, Mills NL, de Lemos JA, Arbab-Zadeh A, Newby LK, et al. Assessment and treatment of patients with type 2 myocardial infarction and acute nonischemic myocardial injury. Circulation. 2019;140(20):1661–78. https://doi.org/10.1161/CIRCULATIONAHA.119.040631
Zhou Q, Yang J, Wang W, Shao C, Hua X, Tang YD. The impact of the stress hyperglycemia ratio on mortality and rehospitalization rate in patients with acute decompensated heart failure and diabetes. Cardiovasc Diabetol. 2023;22(1):189. https://doi.org/10.1186/s12933-023-01908-2
Aronson D, Darawsha W, Promyslovsky M, Kaplan M, Abassi Z, Makhoul BF, et al. Hyponatraemia predicts the acute (type 1) cardio-renal syndrome. Eur J Heart Fail. 2014;16(1):49–55. https://doi.org/10.1093/eurjhf/hft123
Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142–51. https://doi.org/10.1056/NEJMoa0707992
Serpa Neto A, Cardoso SO, Manetta JA, Pereira VGM, Espósito DC, Pasqualucci MOP, et al. Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA. 2012;308(16):1651–9. https://doi.org/10.1001/jama.2012.13730
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