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NYU Medical Grand Rounds
Clinical Vignette
Audrey Pendleton, MD
PGY2
November 29, 2011
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
Patient is a 66 year-old man who presents
with a one-day history of substernal chest
pain
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
The patient was in his usual state of good
health until 1996 when he developed
progressive typical anginal symptoms and
was diagnosed with multi-vessel coronary
artery disease.
He underwent three-vessel coronary artery
bypass graft.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
Over several years, the patient had multiple
re-admissions for typical chest pain in the setting
of poor adherence to anti-platelet medications.
He was found to have 100% occlusive disease in
two grafts and diffuse obstructive coronary
disease in 2006.
In 2009, he underwent percutaneous coronary
intervention with drug-eluting stents to the
proximal left circumflex and obtuse marginal 2,
and maintained on aspirin and clopidogrel.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
Three months prior to presentation, he was
admitted to an outside hospital for an upper
gastrointestinal hemorrhage requiring blood
transfusion.
A diagnostic upper endoscopy was performed
showing evidence of chronic gastritis.
He was discharged in stable condition with
instructions to discontinue aspirin and
clopidogrel.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
The patient returned to his baseline of good
health with unlimited exercise tolerance when
on the morning of presentation while at rest,
he developed substernal pressure-like chest
pain, radiating to both shoulders and with
associated dyspnea.
He took two sublingual nitroglycerin without
relief, and subsequently called an ambulance
and reported to an outside hospital.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
Past Medical History
•Hypertension
•Coronary Artery Disease
•Peripheral Artery Disease
•Diabetes Mellitus, Type 2
•Chronic Kidney Disease, Stage 3
•Gastritis, Upper Gastrointestinal Bleed
Past Surgical History
•Three-vessel coronary artery bypass graft
•Percutaneous coronary intervention with drug-eluting
stents
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Family History
•Mother: Died of myocardial infarction, age 80
•Father: Died of myocardial infarction, age 70
•Social History
•Tobacco: 22 pack year history, quit 16 years ago
•Denies alcohol and illicit drugs
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Medications
•Ramipril 2.5mg by mouth daily
•Spironolactone 25mg by mouth daily
•Furosemide 20mg by mouth daily
•Atenolol 50mg by mouth twice daily
•Amlodipine-Benazepril 5/50mg by mouth daily
•Simvastatin 20mg by mouth at night
•Lansoprazole 30mg by mouth daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: Well-appearing middle-aged man
in no acute distress
•Vital Signs: list T:98.7 BP:155/90, HR:83,
RR: 15, and O2 sat: 100%RA
•Physical exam was otherwise normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC:
•Hemoglobin-11.9 g/dl, hematocrit-35.9%
•Chemistries:
•Cr 1.7mg/dl
•Troponin-15.5 ng/ml
•CK- 545 u/L
(normal 0.1-1.4mg/dl)
(normal <0.059ng/ml)
(normal 45-245u/L)
•The remainder of the lab values were within
normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
ECG: NSR at 80bpm, flattened T waves in I, aVL,
and V6
CXR: normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• Non-ST-elevation myocardial infarction
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
• At the outside hospital he was treated with
aspirin, clopidogrel, metoprolol, sublingual
nitroglycerin, heparin drip and normal saline.
• The patient was then transferred to the Coronary
Care Unit at Bellevue Hospital.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 2-3
• The patient underwent transthoracic
echocardiogram which revealed a depressed EF
of 40% and hypokinesis in the inferior and lateral
walls.
• A cardiac catheterization was performed
showing an acute 70% occlusive thrombus
within the proximal left circumflex stent.
• The patient was changed from heparin to
bivalirudin gtt.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 4 to Discharge
• The patient underwent repeat coronary artery
catherization showing complete resolution of
acute thrombus with an underlying 40%
re-stenosis lesion within the proximal left
circumflex artery stent.
• The patient remained stable without evidence of
hemorrhage on anti-platelet agents.
• He was ultimately discharged home on aspirin
and clopidogrel.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Non-ST-elevation myocardial infarction
due to acute in-stent thrombosis in the
setting of discontinued anti-platelet agents
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS