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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
Chief Complaint
A 66-year-old man presents complaining
of substernal chest and epigastric pain
for thirty minutes.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
Past Medical History
• Hypercholesterolemia
Family History
• Mother: Diabetes mellitus
• Father: Emphysema
Past Surgical History
• Appendectomy
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Social History
• Lifetime non-smoker
• Denies alcohol use
• Denies illicit drug use
Outpatient Medications
Aspirin 81mg Daily
Simvastatin 40mg QHS
No known allergies
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Initial Studies
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Electrocardiogram
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS