Abstract
This case report presents a 37-year-old male with a complex medical history, including HIV, chronic methamphetamine and cocaine use, and an atrial septal defect, who developed severe pulmonary arterial hypertension (PAH), biventricular failure, and recurrent stroke. The patient was admitted with acute neurological deficits and respiratory failure, which rapidly progressed despite intensive management. Laboratory and imaging studies revealed severe cardiac dysfunction and elevated pulmonary vascular resistance. Despite interventions such as venoarterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon support, the patient's condition deteriorated, necessitating a shift toward palliative care. This case highlights the multifactorial etiology of PAH in the context of polysubstance use and HIV, and underscores the challenges of managing complex cardiovascular and neurological sequelae in patients with multiple comorbidities. Multidisciplinary approaches are essential in such cases to optimize patient outcomes and guide future management strategies.