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Clinical Correlations The NYU Langone Online Journal of Medicine http://clinicalcorrelations.org NYU Medicine Grand Rounds Clinical Vignette December 4, 2013 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Chief Complaint • 41 year old woman BIBEMS for one hour of crushing substernal chest pressure UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness •The patient is an active smoker who has not seen a primary care physician for many years other than during pregnancy. •In the weeks prior to presentation, she noted mild shortness of breath and fatigue with exertion, but no prior chest pain. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History •Past Medical History: •None •Past Surgical History: •Cholecystectomy •Tubal ligation •Social History: •Smokes 1 pack per day for over twenty years, denies alcohol or illicit drug use UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History •Family History: •Mother- hypertension, diabetes •Father- hypertension •No known history of early coronary artery disease or sudden death •Allergies: •No Known Drug Allergies •Medications: •No medications UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination •General: Overweight Hispanic woman lying in stretcher in moderate distress •Vital Signs: T: 97.7 F, BP: 141/90, HR: 89, RR: 18, and O2 sat: 100% on room air •Remainder of Physical Exam was normal other than prominent abdominal obesity UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Laboratory Findings •CBC: WBC 13.8 (53% neutrophils) •Remainder of CBC was within normal limits •Basic Metabolic panel: within normal limits •Hepatic panel: within normal limits •Troponin: 0.219, 3.6, >50 •Lipid Panel: Total Cholesterol 133, HDL 23, LDL 46, Triglycerides 322 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS EKG ST elevation in v1-v6, I, aVL, ST depressions in III UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • The patient was taken for urgent cardiac catheterization and had a drug eluting stent placed to the mid-LAD with an ejection fraction of 25% • On hospital day 3, she was discharged on aspirin 81mg, clopidogrel 75mg, atorvastatin 80mg, metoprolol 12.5mg and lisinopril 2.5mg UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Post-discharge Follow-up • In the months following discharge, the patient quit smoking with the use of buproprion and nicotine replacement therapy •She became more physically active, but was not able to significantly change her diet or lose weight. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Post-discharge Follow-up Repeat labs one month after discharge on atorvastatin 80 mg •Fasting lipids- total cholesterol- 138, HDL 29, LDL- 30, triglycerides 397 •HbA1C- 6.6 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Post-discharge Follow-up •Based on this data, atorvastatin was decreased to 40 mg daily, fenofibrate 160 mg daily and metformin 500 mg BID were added. •Lipid panel after several months of this therapy: • Total cholesterol- 143, HDL 30, LDL 82, triglycerides 155 • HbA1C- 5.9 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Follow-up Questions •Is the patient optimally treated on current therapy based on old and new prevention guidelines? •Should any medical therapies be added? •Should any medical therapies be removed? UNITED STATES DEPARTMENT OF VETERANS AFFAIRS