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NYU Medical Grand Rounds
Clinical Vignette
Jacqueline Lonier, PGY2
November 3rd, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• The patient is a 54 year old woman
presenting with chest pain for one month.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient’s history of present illness begins
earlier the year of admission, when she was
diagnosed with type II diabetes, hypertension, and
hyperlipidemia.
•She was in her usual state of health until one
month prior to admission, when she noted the
development of substernal chest pain with
exertion.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Her chest pain progressively worsened,
prompting her to present to an outside hospital.
•During her workup there, she underwent stress
testing which was positive for ischemia.
•She was then transferred to Bellevue Hospital for
further evaluation.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Hypertension
•Hyperlipidemia
•Type II diabetes
•Past Surgical History:
•None
•Social History:
•No history of tobacco, alcohol, or drug use
•She is unemployed
•Family History:
•No history of early coronary artery disease or diabetes
•Allergies:
•No known drug allergies
•Medications:
•Lisinopril 10 mg daily
•Metoprolol 25 mg twice daily
•Simvastatin 80 mg daily
•Metformin 500 mg twice daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: Well-developed, well-nourished and in no
acute distress
•Vital Signs: T 97.2, BP 110/70, HR 71, RR 16,
O2 sat 98% on room air
•The remainder of the physical exam was normal.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: within normal limits
•Basic Metabolic Panel: within normal limits
•Hepatic Panel: within normal limits
•Lipid Panel: Total Cholesterol 129 (<200), HDL 28 (38-92),
LDL 68 (<130), Triglycerides 164 (55-250)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•Electrocardiogram: Normal sinus rhythm
with T-wave flattening in V3-V6
•Chest X-Ray: no abnormalities
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• Unstable angina
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– The patient underwent cardiac
catheterization, which demonstrated 75%
occlusion of the proximal left anterior
descending artery, 80% occlusion of the distal
left anterior descending artery, and 80%
occlusion of the right coronary artery.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– The patient was considered for enrollment in
the FREEDOM trial, a prospective
randomized trial comparing the effectiveness
of multivessel stenting using drug-eluting
stents, to Coronary Artery Bypass Grafting in
patients with diabetes mellitus and multivessel
coronary artery disease.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– The cardiology fellow informed the
FREEDOM trial coordinator about the results
of the patient’s catheterization.
– The coordinator explained the trial to the
patient and left the consent with the patient to
be reviewed and read with family members.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 2:
– The cardiovascular surgeons and
interventional cardiologists agreed that the
patient was a study candidate.
– The patient agreed to be in the study and
signed the consent, and was randomized to
the percutaneous coronary intervention arm of
the trial.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Interim History
• The patient was discharged and was then electively
re-admitted one month later for percutaneous
coronary intervention.
• A drug-eluting stent was placed in the right coronary
artery without complication.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Interim History
• The patient was electively admitted a second time
one month later. Drug-eluting stents were placed in
the proximal and distal left anterior descending
artery. The patient was discharged with outpatient
follow-up.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Unstable angina secondary to multivessel
coronary artery disease, due to multiple
risk factors including hypertension,
hyperlipidemia and type II diabetes
mellitus.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS