Medical Grand Rounds Clinical Vignette
December 5, 2007
By: Benjamin Bergman, M.D.
Chief Complaint
73 year-old man presented with chest pain radiating to the left arm
History of Present Illness
• One day prior to admission, exertional chest pain improved with rest and sublingual nitroglycerin
• Awoke with severe “burning chest pain” in epigastrium radiating to left arm
Review of Systems
• Patient denies recent change in medications or non-compliance • Denied palpitations, dyspnea, pleuritic pain, cough, signs of bleeding, hemoptysis, back pain, syncope
Other History
PMH: hypercholesterolemia, tobacco use, myocardial infarction in 2005 complicated by ventricular tachycardia s/p AICD, recurrent myocardial infarction in 2007, evaluated with coronary angiogram.
Further History
Medications: • Lisinopril 5 mg, isosorbide dinitrate 10 mg, ezetimibe/simvastatin 10/80 mg, aspirin 81 mg, clopidogrel 75 mg Allergies: None Family History: No premature coronary artery disease or sudden cardiac death.
Physical Exam
GENERAL: ill-appearing male, dyspneic VS: BP 124/76 mmHg, HR 54 bpm, RR 22/min, O2 saturation 95% on room air, T 99.2 F HEART: no JVD, regular rhythm, no murmurs or gallops CHEST: faint bibasilar crackles EXT: cool, no peripheral edema The remainder of the exam was normal.
Labs and EKG
• Troponin 0.4 21.9 • Creatinine 1.3 (baseline 0.9)
• EKG: sinus rhythm, normal axis and intervals, 2 mm ST depression in I, aVL, V5, V6, no ST elevations
Radiologic data
• CXR: pulmonary vascular prominence and cardiomegaly, no consolidations or effusions
• Transthoracic Echocardiogram: EF 30%, mild aortic regurgitation, moderate mitral regurgitation, inferior akinesis and thinning, LV dilation (5.9cm), severe apical inferior and anterior akinesis
Diagnosis
• Unstable angina pectoris/Non-ST elevation myocardial infarction, high risk • TIMI risk score 7/7, 41% risk of recurrent event at 14 days • Killip Class II (mild congestive heart failure)
Hospital Course
• Transferred to CCU for closer observation and urgent percutaneous coronary intervention (PCI) • Treated with ASA, plavix, unfractionated heparin, and tirofiban • Cardiac catheterization revealed progression of ramus intermedius branch lesions
Hospital Course
• Received drug eluting stents to both branches of ramus intermedius with resolution of chest pain
Final Diagnosis
• Coronary artery disease, recurrent non-ST elevation myocardial infarction
April 2007 coronary angiogram: -moderate RCA proximal lesions, with severe distal RCA lesions -normal LM with severe lesions at both branches of bifurcating ramus intermedius off LM (medical management due to complicated intervention with overlapping stents at bifurcation) -50% proximal LCx with diffuse distal disease -40% LAD disease