NYU Medical Grand Rounds Clinical Vignette

1. NYU Medical Grand Rounds Clinical Vignette Brandon Oberweis - PGY2 September 6, 2011 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 66 year old male with substernal chest tightness for 1 hour duration

3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient was in his usual state of health until the afternoon on the day of admission, when he was running to catch a train • The patient had an acute episode of severe, substernal chest tightness, without radiation • The chest pain was accompanied by diaphoresis and unrelieved by rest, prompting the patient to call EMS • EMS arrived and the patient was transported to the Bellevue Hospital

4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • Hypertension • Past Surgical History: • Left inguinal hernia repair • Social History: • 1 glass of wine daily • Currently unemployed • Family History: • Noncontributory • Allergies: • No Known Drug Allergies • Medications: • Amlodipine 5mg PO daily

5. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: laying in bed endorsing mild chest discomfort, no acute distress • Vital Signs: T: 98.2°F BP: 159/102 HR: 97 RR: 22 and O2 sat: 97% on room air • Cardiac: S4 heart sound at the apex • Pulmonary: bibasilar crackles bilaterally • Remainder of physical exam was normal

6. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: WBC 13.5 (N 74, L 17, M 8, E 1, B 0) • Remainder of CBC was within normal limits • Basic Metabolic panel: within normal limits • Hepatic panel: AST 495, ALT 94 • Remainder of hepatic panel was within normal limits • 1st troponin 0.044, 2nd troponin > 50

7. ECG UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

8. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working or Differential Diagnosis • Acute anterior wall ST-elevation myocardial infarction

9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • Patient was given sublingual nitroglycerin x1, with little relief • STEMI alert was called • Patient received aspirin 325mg, clopidogrel 600mg, and was given a heparin bolus and then started on a heparin drip • Patient was taken from the Emergency Department to the cardiac catheterization laboratory (door-to-balloon time was 37 minutes)

10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • Cardiac catheterization: • Right dominant • Left Coronary System: • LAD (proximal): discrete 100% lesion • LAD (distal): discrete 50% lesion • Diag1 (proximal): discrete 60% lesion • Diag2 (proximal): discrete 70% lesion • Circumflex (proximal): luminal irregularities 20% lesion • Proximal ramus: 80% lesion • Right Coronary System: • Right coronary (proximal): discrete 70% lesion • Right coronary (distal): diffuse 40% lesion

11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • Cardiac catheterization: • Drug-eluting stent was placed to the proximal LAD • 2-hours post-catheterization, the patient became unresponsive, and was found to be in ventricular fibrillation • Patient underwent 1 round of CPR and defibrillation with 200J, which resulted in conversion to normal sinus rhythm

12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • The patient was started on an amiodarone drip • He was taken for repeat cardiac catheterization, which revealed no in-stent thrombosis or acute plaque rupture • The patient returned to the Coronary Care Unit and started on a lidocaine drip

13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 2: • Transthoracic echocardiogram was performed showing ejection fraction 30%, severe apical posterior wall hypokinesis, akinesis of apical interventricular septum, left ventricular apex, apical lateral wall, apical inferior wall, left ventricular apical anterior wall

14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 3: • Patient experienced repeat episode of hypotension to 70/50 mmHg following furosemide 80mg, bumetanide 0.5mg, and tamsulosin • Blood pressure improved with normal saline 250cc bolus and discontinuation of diuretics and tamsulosin • Repeat transthoracic echocardiogram ejection fraction 25%, akinesis of apical interventricular septum, left ventricular apex, severe anterior wall hypokinesis, and a 1.2x1.1cm left ventricular thrombus. Patient was therefore continued on heparin drip for bridge to coumadin

15. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 8-18: • The patient was transferred from the Coronary Care Unit to regular floor. • Patient was fitted for a LifeVest • Carvedilol and lisinopril were re-initiated • Anticoagulation with heparin was bridged to therapeutic coumadin • Patient was discharged home on hospital day #18

16. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Acute anterior wall ST-elevation myocardial infarction complicated by ventricular fibrillation arrest, left ventricular thrombus and severely depressed left ventricular function.

17. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Follow-Up • Repeat transthoracic echocardiogram 2 weeks following discharge showed EF 30-35%, akinesis of apical interventricular septum, left ventricular apex, and severe hypokinesis of apical anterior wall, hypokinesis of apical wall, no evidence for LV thrombus • The patient has been continued on coumadin for a plan of 6 month duration • Repeat transthoracic echocardiogram is pending. If there is no improvement in ejection fraction, patient will likely require AICD implantation