Myocardial Infarction grand rounds

Department of Medicine Grand Rounds Case Vignette Parveen Garg, M.D. September 20th, 2006 • CC: A 56 year-old male complains of new-onset nocturnal chest pain for the past two weeks • HPI: Pt started smoking 1 pack-per-day 35 years ago, developed hypertension 20 years ago that has been well-controlled with medications, and was in his usual state of health until two weeks ago. He reported newonset chest pain that started at night and in the early morning. The pain is described as sharp, localized to the substernum, and radiating to the neck and jaw. The pain often wakes him up at night and resolves within minutes after waking. He is currently having an episode of chest pain, however, that has not resolved. He denies any nausea, vomiting, shortness of breath, or diaphoresis. • Family History: His father died of a heart attack at age 50. Physical Exam • General: Well-developed, healthy-appearing male, appearing stated age, in distress • T: 96.8 HR: 67 BP: 130/67 RR: 20 • Cardiovascular: no jugular venous distension, regular rate and rhythm, normal heart sounds, no murmurs appreciated, good distal pulses • Chest: Clear to auscultation bilaterally, no crackles Electrocardiogram • Normal Sinus Rhythm. 1-2mm downsloping ST depressions in V2-V6. Imaging / Labs • Echocardiogram: The left ventricle is normal in size. There is no thrombus. There is normal left ventricular wall thickness. Apical septum is akinetic (normal on prior imaging). • Cardiac Enzymes: Troponin I peaked to 9.2 Diagnostic Procedure – Cardiac Catheterization • Catheterization revealed a 95% ostial lesion with thrombus in the Left Circumflex artery and diffuse narrowing of the artery distally. A 70% mid-lesion was also noted in a small Right Coronary Artery. Therapeutic Course • Stenting of the Ostial LCX artery was performed. The stent was post dilated with a 3 mm x 6 mm balloon and an excellent angiographic result was achieved. • Patient remained stable post-operatively and chest pain free. • Patient was discharged to home two days later on an appropriate cardiac medication regimen – Zocor, Toprol, Lisinopril, Plavix, and ASA – and instructed to follow-up with cardiology. Final Diagnosis • Non-ST elevation myocardial infarction secondary to occlusion of the Left Circumflex Artery