Download Journal Club - Bellevue Hospital

NYU Medical Grand Rounds
Clinical Vignette
Brandon Oberweis - PGY2
September 6, 2011
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
•66 year old male with substernal chest
tightness for 1 hour duration
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient was in his usual state of health
until the afternoon on the day of admission,
when he was running to catch a train
•The patient had an acute episode of severe,
substernal chest tightness, without radiation
•The chest pain was accompanied by
diaphoresis and unrelieved by rest, prompting
the patient to call EMS
•EMS arrived and the patient was transported
to the Bellevue Hospital
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Hypertension
•Past Surgical History:
•Left inguinal hernia repair
•Social History:
•1 glass of wine daily
•Currently unemployed
•Family History:
•Noncontributory
•Allergies:
•No Known Drug Allergies
•Medications:
•Amlodipine 5mg PO daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: laying in bed endorsing mild chest
discomfort, no acute distress
•Vital Signs: T: 98.2°F BP: 159/102 HR: 97
RR: 22 and O2 sat: 97% on room air
•Cardiac: S4 heart sound at the apex
•Pulmonary: bibasilar crackles bilaterally
•Remainder of physical exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: WBC 13.5 (N 74, L 17, M 8, E 1, B 0)
•Remainder of CBC was within normal limits
•Basic Metabolic panel: within normal limits
•Hepatic panel: AST 495, ALT 94
•Remainder of hepatic panel was within normal
limits
•1st troponin 0.044, 2nd troponin > 50
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
ECG
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• Acute anterior wall ST-elevation
myocardial infarction
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– Patient was given sublingual nitroglycerin x1, with
little relief
– STEMI alert was called
– Patient received aspirin 325mg, clopidogrel
600mg, and was given a heparin bolus and then
started on a heparin drip
– Patient was taken from the Emergency
Department to the cardiac catheterization
laboratory (door-to-balloon time was 37 minutes)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– Cardiac catheterization:
• Right dominant
• Left Coronary System:
–
–
–
–
–
–
LAD (proximal): discrete 100% lesion
LAD (distal): discrete 50% lesion
Diag1 (proximal): discrete 60% lesion
Diag2 (proximal): discrete 70% lesion
Circumflex (proximal): luminal irregularities 20% lesion
Proximal ramus: 80% lesion
• Right Coronary System:
– Right coronary (proximal): discrete 70% lesion
– Right coronary (distal): diffuse 40% lesion
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– Cardiac catheterization:
• Drug-eluting stent was placed to the proximal LAD
– 2-hours post-catheterization, the patient became
unresponsive, and was found to be in ventricular
fibrillation
– Patient underwent 1 round of CPR and defibrillation
with 200J, which resulted in conversion to normal
sinus rhythm
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– The patient was started on an amiodarone drip
– He was taken for repeat cardiac catheterization,
which revealed no in-stent thrombosis or acute
plaque rupture
– The patient returned to the Coronary Care Unit and
started on a lidocaine drip
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 2:
– Transthoracic echocardiogram was performed showing
ejection fraction 30%, severe apical posterior wall
hypokinesis, akinesis of apical interventricular septum, left
ventricular apex, apical lateral wall, apical inferior wall, left
ventricular apical anterior wall
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 3:
– Patient experienced repeat episode of hypotension to
70/50 mmHg following furosemide 80mg, bumetanide
0.5mg, and tamsulosin
– Blood pressure improved with normal saline 250cc
bolus and discontinuation of diuretics and tamsulosin
– Repeat transthoracic echocardiogram ejection
fraction 25%, akinesis of apical interventricular
septum, left ventricular apex, severe anterior wall
hypokinesis, and a 1.2x1.1cm left ventricular
thrombus. Patient was therefore continued on heparin
drip for bridge to coumadin
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 8-18:
– The patient was transferred from the Coronary Care
Unit to regular floor.
– Patient was fitted for a LifeVest
– Carvedilol and lisinopril were re-initiated
– Anticoagulation with heparin was bridged to
therapeutic coumadin
– Patient was discharged home on hospital day #18
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Acute anterior wall ST-elevation
myocardial infarction complicated by
ventricular fibrillation arrest, left ventricular
thrombus and severely depressed left
ventricular function.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Follow-Up
• Repeat transthoracic echocardiogram 2 weeks following
discharge showed EF 30-35%, akinesis of apical
interventricular septum, left ventricular apex, and severe
hypokinesis of apical anterior wall, hypokinesis of apical
wall, no evidence for LV thrombus
• The patient has been continued on coumadin for a plan
of 6 month duration
• Repeat transthoracic echocardiogram is pending. If there
is no improvement in ejection fraction, patient will likely
require AICD implantation
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS