Medical Grand RoundsMedical Grand RoundsClinical VignetteClinical Vignette

October 15October 15thth, 2008, 2008

Srikant Duggirala, M.D.Srikant Duggirala, M.D.

Chief ComplaintChief Complaint

57 year old male presents with chest pain 57 year old male presents with chest pain for 12 hoursfor 12 hours

History of Present IllnessHistory of Present Illness

On the evening prior to admission, the patient reports the On the evening prior to admission, the patient reports the sudden onset of sub-sternal chest pain while doing sudden onset of sub-sternal chest pain while doing housework. The pain radiated to the jaw and left arm. housework. The pain radiated to the jaw and left arm. The chest pain was associated with mild shortness of The chest pain was associated with mild shortness of breath, diaphoresis and nausea with no vomiting. He breath, diaphoresis and nausea with no vomiting. He denied any palpitations or prior episodes of similar chest denied any palpitations or prior episodes of similar chest pain. pain.

He denied any recent cocaine use. He denied any recent cocaine use.

He recalls a normal exercise stress test several years He recalls a normal exercise stress test several years ago done at another hospital.ago done at another hospital.

HistoryHistory

Past Medical History: Past Medical History: – DepressionDepression– AsthmaAsthma

Past Surgical History: Past Surgical History: – No prior surgeriesNo prior surgeries

HistoryHistorySocial Hx:Social Hx: – 44 pack year history of smoking, current 1ppd smoker44 pack year history of smoking, current 1ppd smoker– Smoked Cocaine for 40 years, quit 2 months agoSmoked Cocaine for 40 years, quit 2 months ago

– Drank 5 12-ounce beers daily for 10 years. Quit 2 Drank 5 12-ounce beers daily for 10 years. Quit 2

months ago after completingmonths ago after completing a 10 a 10 month in-patient month in-patient

rehab program.rehab program. Family Hx:Family Hx: – Father died of MI at age 65Father died of MI at age 65

Allergies: Allergies: – No known drug allergiesNo known drug allergies

Medications:Medications:– MVIMVI

Physical ExamPhysical ExamGeneral:General: In no acute distress, appeared stated age.In no acute distress, appeared stated age.

T:98.8T:98.8ooF BP:147/70 HR:76 RR:18 F BP:147/70 HR:76 RR:18 OO2:98%RA:98%RA

HEENT:HEENT: No JVD or carotid bruits noted. No JVD or carotid bruits noted.CV:CV: Normal S1 and S2. No murmurs, rubs or gallops. Normal S1 and S2. No murmurs, rubs or gallops.Pulm:Pulm: Clear to auscultation bilaterally Clear to auscultation bilaterallyExt:Ext: No clubbing, cyanosis or edema. 2+ dorsalis No clubbing, cyanosis or edema. 2+ dorsalis

pedis pulse and 2+ femoral pulses bilaterallypedis pulse and 2+ femoral pulses bilaterally

The remainder of the physical exam was normalThe remainder of the physical exam was normal

LaboratoryLaboratory

WBC of WBC of 15.1315.13AST of AST of 7373 (Normal 0-40) (Normal 0-40)

Basic Metabolic Panel normalBasic Metabolic Panel normalUrine Toxicology negative for opiatesUrine Toxicology negative for opiates

Time 0 hours Time 8 hours

Troponin 0.935 2.363

CK 392 611

CK-MB 37 77.8

ImagingImagingECG: ECG: Sinus rhythm with rate of 66, LAFB, Left Atrial Sinus rhythm with rate of 66, LAFB, Left Atrial enlargement, TWI in V4-V6enlargement, TWI in V4-V6

Chest XRChest XR: : No evidence of pulmonary congestion or No evidence of pulmonary congestion or effusions.effusions.

Working DiagnosisWorking Diagnosis

Non-ST Elevation Myocardial Infarction Non-ST Elevation Myocardial Infarction (NSTEMI)(NSTEMI)

Hospital CourseHospital Course

ED course: ED course: – Treated with: Treated with:

Aspirin 325mgAspirin 325mg

Clopidogrel 300mgClopidogrel 300mg

Enoxaparin 70mgEnoxaparin 70mg

Morphine 4mg IVPMorphine 4mg IVP

Sub-lingual Nitroglycerine 0.4mg and Nitropaste Sub-lingual Nitroglycerine 0.4mg and Nitropaste

The patient remained hemodynamically The patient remained hemodynamically stable and his chest pain resolved. stable and his chest pain resolved.

Hospital CourseHospital CourseThe patient was taken for a Diagnostic Cardiac Catheterization showing:– Mid RCA 40-50% – Distal RCA 75% – Proximal LCx of 70% – OM2 with 99%

Ventriculogram showed EF of 55% with moderate posterior- lateral wall hypokinesis.

Hospital CourseHospital CourseOn HD#2, the patient transferred to Bellevue On HD#2, the patient transferred to Bellevue Hospital CCU for rescue Percutaneous Hospital CCU for rescue Percutaneous Coronary Intervention (PCI) of the proximal left Coronary Intervention (PCI) of the proximal left circumflex and obtuse marginal lesions.circumflex and obtuse marginal lesions.

Upon transfer, the patient developed a BP of Upon transfer, the patient developed a BP of 190/100 and was started on nitroglycerine drip. 190/100 and was started on nitroglycerine drip. He remained chest pain free.He remained chest pain free.

On HD#3, he was started on a beta-blocker and On HD#3, he was started on a beta-blocker and ACE-inhibitor and titrated off the nitroglycerine ACE-inhibitor and titrated off the nitroglycerine drip.drip.

Hospital CourseHospital Course

On HD #4, he had rescue PCI of his lesions On HD #4, he had rescue PCI of his lesions with Endeavor stents. with Endeavor stents.

He remained CP free and was discharged on a He remained CP free and was discharged on a beta-blocker, ACE-Inhibitor, Clopidogrel and beta-blocker, ACE-Inhibitor, Clopidogrel and AspirinAspirin

Follow-upFollow-up

He is scheduled to return to the Bellevue He is scheduled to return to the Bellevue Hospital Catheterization lab in 4-6 weeks Hospital Catheterization lab in 4-6 weeks for elective PCI of his distal RCA lesion.for elective PCI of his distal RCA lesion.

He was also educated about smoking cessation.

Final DiagnosesFinal Diagnoses

NSTEMI from coronary artery disease. NSTEMI from coronary artery disease.