Morbidity and Mortality

1. Morbidity and Mortality 1/30/02 G. Jeremy Juriansz

2. History of Present Illness: -81 y/o male presented to outside facility with a chief complaint of sudden onset of cough and SOB which awoke pt from sleep. -Pt denied symptoms of CP/pressure, diaphoresis, N/V, shoulder or neck pain.

3. Past Medical History: #ASCVD: Myocardial Perfusion/Thallium Scan 05/9/97: Moderate inferoapical ischemia; probable inferobasal MI. Cath ’97: 30% ostial LM, 70% mid LAD 65% proximal LCX, 75% mid LCX 100% occlusion RCA EF 70% #DM II: controlled with oral agents #HTN: poorly controlled #PVD: Rt lower extremity arterial bypass and subsequent BKA ’96 S/P Right CEA ’86; f/u carotid angiogram 10/95 showed 20% Rt occlusion and 40% Lt occlusion. #Hypercholesterolemia: on HMG Co-A reductase inhibitor.

4. Social History: Pt lived in Glover, Vermont and worked at Tap and Dye plant as a factory worker; trucker and logger in the past. Non-smoker and no alcohol. • Family History: Father died of an MI (unspecified age at death) Mother died of CA (unspecified type and age at death) Brother died from MI in his ’80’s. • Allergies: PCN  Rash

5. Medications: • HCTZ 25 mg po qd • Lisinopril 20 mg po qd • Felodipine 10 mg po qd • Atenolol 25 mg po qd • Lovastatin 10 mg po qd • Metformin 500 mg po qd • Glyburide 10 mg po bid • Ranitidine 150 mg po bid

6. Physical Exam: Gen: Pt in distress with labored respirations VS: T37.1 BP 244/101HR 102R40 SaO2 82% RA; 98% on 50% O2 via NRB Face Mask HEENT: EOMI, PERRLA, OP clear, no adenopathy NECK: JVP ~ 10 cm H20, no carotid bruits CV: Tachycardic, Regular, S3 present, no S4, no murmur, no rub LUNG: Tachypnea, no dullness to percussion, crackles from bases to 1/3 of lung fields bilaterally, no rhonchi ABD: Soft, NT, NABS, no masses, no organomegaly RECTAL: Normal tone, no mass, guaiac neg EXT: Right BKA, no CCE NEURO: Grossly intact/Non-focal

7. Initial Management: • EKG • Metoprolol 5 mg IV x 2  SBP 170 HR 84. • IV nitrates and diuretics. • CBC, Chem-7, coags, cardiac enzymes. • ABG • Portable CXR

8. EKG #1

9. LABS: 16.4 134 102 28 5.5 204 4.3 21 1.5 40.2 • pH 7.25, PCO2 55, PO2 88, O2 sat 96, HCO3 23 (100% NRB FM) • PT/INR: 12.5/1.0 • CPK/Troponin I: 40/0.02 • CXR: Cardiomegly with bibasilar effusions suggestive of CHF; No infiltrate.

10. EKG #2

11. Impression: -Acute/flash pulmonary edema -Admitted to the outside facility’s ICU for further management -serial q 8 hr CPK/troponin I(s): 40/0.02 -> 39/0.38 -> 34/0.70 -> 18/0.27 • Plan: Hospital Days 1-4  Symptomatic treatment via nitro gtt and intravenous diuretics. ASA. Heparin therapy was not instituted over this time period.  BP control with felodipine, lisinopril, NTG paste and labetalol

12. Hospital Day 5: • Transthoracic ECHO: EF 50%, inferobasilar hypokinesis, posterobasilar akinesis, and posterior hypokinesis. • Transfer to DHMC cardiology service for cardiac catheterization.

13. Medications on transfer: • EC ASA 325 mg po qd • Felodipine 15 mg po qd • Labetalol 200mg po bid • Lisinopril 40 mg po qd • NTG paste 2” topical q 6 hrs • Omeprazole 20 mg po qd • Furosemide 20 mg po qd • Lovastatin 10 mg po qd • Sliding scale regular insulin • Note that Heparin Gtt added to pt regimen upon admission to DHMC.

14. 220 • DHMC Admission Labs: CBC: LYTES: 14.6 127 105 33 6.4 218 6.2 17 1.6 45.2 • Coags: PT 12.7, INR 1.0, PTT 26 • Lipids: T. Chol 201, HDL 34, LDL 142, Trig 127

15. DHMC Admission EKG: Sinus (95) with 1st degree A-V block; LVH with repolarization abnls; old inferior infarct (cited 7/7/97); ST depression in anterolateral leads. • Code status DNR/I discussed and pt agreed to have status suspended for the catheterization procedure. • Pt was sent to cardiac catheterization laboratory.

16. Cath Report: Left Heart Pressure (Aortic pressure): Systolic 143 Diastolic 40 Mean 71 Dominance: Right Left Main: 30% ostial stenosis LAD: Mild diffuse dz throughout vessel Mid LAD single discrete 75% stenosis Left Circ: Mild diffuse dz Ostial OM1 70% stenosis; Ostial OM2 75% stenosis. RCA: Not injected 2ndary to prior cath showing total occlusion. Observation of RCA filling through collaterals. • Cardiac Cath Conclusion: • Obstructive LAD and LCX dz with Non-obstructive LM dz with recommendation that pt be managed by medical therapy. No intervention done at this time.

17. Post Catheterization Angina: • Subjective: Sensation of tightness, SOB, nausea and diaphoresis • Objective: P 95 BP 180/89 Cardiac Exam: Regular, nom/g/r Lung: Rales in bases bilaterally EKG: unchanged from admission. • Interventions: NTG SL x 2, Metoprolol 5 mg IV, Furosemide 20 mg IV Nitro gtt initiated HCTZ 25 mg po qd Labetalol d/c’d Metoprolol 100 mg po q 8 hrs

18. Hospital Day 7: • Pt stated that he did not want to have a CABG • BP poorly controlled (180’s/60’s), started on minoxidil 5 mg po qd and HCTZ was incr’d to 50 mg po qd • NTG gtt weaned off • Worse renal function with BUN/Cr 45/1.6 and K 5.6 • Kayexalate 30g po x1 • Lisinopril held • Cardiac rehab with ambulation started. Primary team questioned if pt could be dischg’d home the following am.

19. Hospital Day 9: Overnight cross covering intern called to bedside @ midnight for anginal chest pain • CP pain unrelieved by NTG SL x 3 • EKG: Sinus tach (104); ST depression > 1mm in leads I, V4-V6; ST elevation > 1mm in leads V1, aVR and III • CPK 41/TNT 0.21 • NTG gtt started and pt had CP relieved

20. Hospital Day 9 (continued): - CT surgery consulted for possible CABG candidacy - Mortality risk estimated to be 10-15% • Hospital Day 10: - Pt agreed to have CABG surgery - Plan to use bilateral IMA’s - On the OR schedule in 2 days

21. Hospital Day 11: • Discussion between 4E cardiology service attending, cardiology interventionalist and CT surgeon. • Decision made to perform a percutaneous procedure instead of CABG. • Hospital Day 13: • ECHO performed to eval LVEF and WMAs. • Acetylcysteine given pre-procedure • Taken to cath lab for intervention

22. The New England Journal of MedicinePREVENTION OF RADIOLOGIC-CONTRAST-AGENT INDUCED REDUCTIONS IN RENAL FUNCTION BY ACETYLCYSTEINE p=0.01 Absolute Risk Reduction = 0.19 Number Needed To Treat = 1/ARR = 5.26 Tepel M, et al. NEJM 2000;343:180-184.

23. Left Coronary Artery Left Anterior Oblique View Right Coronary Artery Right Anterior Oblique View

24. Hospital Day 14: • 100% O2 via NRB FM ;Sp02 at 85% with BP 200’s/90’s. • ABG: pH 7.24, CO2 40, HCO3 17.1, PO2 269, FiO2 100 • CPK/TNT: 179/0.49 • 50% O2 via BiPAP • Furosemide 40 mg IV x 1, heparin gtt • Transferred to CCU • CP returned, began eptifibatide gtt and NTG gtt.

25. Hospital Day 15 (continued) • Morning rounds JVP >20 cm H2O, crackles throughout both lung fields with S3 and S4 present. • AM Labs: 13.4 11.3 270 136 107 55 42.3 6.4 14 2.8 CPK/TNT: 2156/6.0  2101/15.76 EKG performed

26. EKG #3

27. Cardiac Catheterization #3 LCX Mid 80% lesion that was stented LCX 99% proximal OM1 stenosis that was stented Both stents were noted to be without residual stenosis and with normal distal flow. LAD was noted to have moderate diffuse dz and no intervention was performed on this vessel at this time.

28. EKG #4

29. Hospital Day 15: • Pt without events overnight • LABS: BUN/Cr: 66/4.2, CPK/TNT 2250/38.55 • Renal consult requested • CCU attending had conversations with family and pt who agreed to have dialysis if necessary. DNR/I status reconfirmed.

30. Hospital Day 16: • Junctional heart rhythm in the 30’s and patient unresponsive • Asystole • Pronounced dead at 1:55 am • Family declined autopsy