NYU Medical Grand Rounds Clinical Vignette Jeremy R. Beitler MD, PGY-2 December 16, 2009 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS
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NYU Medical Grand Rounds Clinical Vignette
Jeremy R. Beitler MD, PGY-2
December 16, 2009
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
A 66-year-old man presents complaining of substernal chest and epigastric pain for thirty minutes.
Chief Complaint
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• The patient was in his usual state of good health until thirty minutes prior to presentation in the emergency room.
• He reported a previously unlimited exercise tolerance.
• He denied having previous episodes of chest pain.
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Thirty minutes prior to presentation, the patient noted the sudden onset of non-radiating substernal chest pressure while climbing a flight of stairs.
• The pain did not resolve with rest.
• The chest pain was associated with dyspnea, diaphoresis, epigastric discomfort and a single episode of vomiting.
• EMS was called. Aspirin 162mg was administered and the patient was brought to the Bellevue Hospital Emergency Room.
Additional History
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Past Medical History• Hypercholesterolemia
Past Surgical History• Appendectomy
Family History• Mother: Diabetes mellitus• Father: Emphysema
Social History• Lifetime non-smoker• Denies alcohol use• Denies illicit drug use
Outpatient Medications
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Aspirin 81mg Daily
Simvastatin 40mg QHS
No known allergies
Physical Examination
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
General: Slightly pale and diaphoretic man in mild distress
Vitals: T 97.0F, BP 134/92, HR 55, RR 22
O2 saturation: 99% on room air
Cardiac: Non-displaced point of maximal impulse, no murmurs or rubs, no elevation of jugular venous pressure, 2+ distal pulses
Pulmonary: Clear to auscultation
Abdominal: Mild epigastric tenderness
The remainder of the physical exam was normal.
Initial Studies
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
CBC: Within normal limits
Basic Metabolic Panel: Within normal limits
Hepatic Panel: Within normal limits
Troponin-I: 0.128 ug/dL (< 0.059 ug/dL)
CXR: Within normal limits
Electrocardiogram
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Working Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Non-ST Elevation Myocardial Infarction
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Hospital Course
• Fifteen minutes after arriving in the emergency room, the patient’s blood pressure fell to 80/30 mmHg. A 1 Liter bolus of normal saline was administered with return of a normal blood pressure.
• Due to the transient hypotension, the cardiology consult service was called to evaluate the patient.
• At the time of the cardiology consultant’s examination, the patient had developed diffuse bilateral rales. The ECG was interpreted as extensive anterior infarction with ongoing ischemia.
• The ST-elevation myocardial infarction team activated, and Clopidogrel 600mg and Atorvastatin 80mg were administered.
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• The patient was taken emergently to the cardiac catheterization laboratory where diagnostic angiography demonstrated:
• Total occlusion of the proximal LAD with angiographic features consistent with acute thrombus
• 90% stenosis of the mid RCA
• During the procedure, the patient developed ventricular fibrillation. He was successfully defibrillated and maintained on lidocaine.
• Percutaneous coronary intervention was performed on the proximal LAD lesion with deployment of a drug-eluting stent.
• Door-to-Balloon Time: 70 Minutes
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• The patient was admitted to the coronary care unit for observation and initiation of optimal medical therapy.
• Troponin measurements peaked at levels greater than 50 ug/dL.
• Transthoracic echocardiography demonstrated an LVEF of 33% with severe hypokinesis of the intraventricular septum, anterior walls and apical regions.
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Final Diagnosis
Acute Transmural Anterior Wall Myocardial Infarction
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