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  • 4 main risk factors associated w/ increased risk is smoking, high Apo protein, history of hypertension, and diabetes. In this study they also found that the rates of fruit and vegetable consumption were quite lower

safari test safari test Presentation Transcript

  • CCU Case Conference
  • Chief Complaint
    • 45 yo Pakistani M with HTN, diet controlled hyperlipidemia, psoriasis presents with 5/10 midsternal chest pain with nausea while driving home from work that lasted one hour
  • History of Present Illness
    • Patient’s pain began suddenly at 4:30 pm and was not exacerbated with exertion. He took acetaminophen which offered no relief.
    • At 5:30 pm, the patient continued to have pain which prompted him to call the EMS.
  • Past Medical History
    • PMH: HTN, borderline hyperlipidemia, psoriasis
    • Meds: on HTN meds which he did now the names that he took irregularly
    • ROS: negative
    • What were his cardiac risk factors?
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  • South Asians and CV risk
  • Physical Exam
    • Gen: Anxious, AOx3, NAD
    • VS: 98.9 108/81 103 reg 114 98% RA
    • 65 in 202 lbs
    • HEENT: MMM
    • Neck: JVP around 8 cm
    • CV: Tachy, RRR systolic murmur III/VI at LLSB, RV heave
    • Lungs: b/l crackles at bases
    • Abd: Soft
    • Ext: Warm, 2+ pedal pulses, dry scaly skin at shins b/l
  • Laboratory Assessment 8.5 8.5 – 10.5 Calcium (mg/dl) 136 70 - 110 Glucose (mg/dl) 1.5 0.6 – 1.5 Creatinine (mg/dl) 20 8 – 25 Urea nitrogen (mg/dl) 22 23.0 – 31.9 Carbon dioxide (mmol/liter) 102 100 – 108 Chloride (mmol/liter) 5.4 3.4 – 4.8 Potassium (mmol/liter) 137 135 – 145 Sodium (mmol/liter) CHEMISTRY ON ADMISSION REFERENCE RANGE TEST
  • Laboratory Assessment 0 2-8 Bands 1.1 11.3 – 13.3 INR 13.9 22.1 – 35.1 Partial-thromboplastin time (sec) 269 150,000 – 300,000 Platelet Count (per mm 3 ) 11 4 – 11 Monocytes 15 22 – 44 Lymphocytes 74 40 – 70 Neutrophils Differential Count (%) 15.0 4,500 – 11,000 White-cell count (per mm 3 ) 41.3 41.0 – 53.0 Hematocrit (%) 13.9 13.5 – 17.5 Hemoglobin (g/dl) HEMATOLOGY ON ADMISSION REFERENCE RANGE TEST
  • Laboratory Assessment
    • Troponins 12
    • CK
    • CK MB 24
    • BNP
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  • Hospital Course
    • Overnight, the patient remained tachycardic, but his blood pressure was stable. The patient, however, did have increasing oxygen requirements.
    • He was started on nitroprusside to maintain a systolic blood pressure < 110 mmHg
  • Hospital Course
    • On HD # 2, a intra-aortic balloon pump was placed to improve the patient’s cardiac output. Throughout the patient remained stable but continued to have worsening pulmonary edema
    • The following blood gases were drawn to meaure a shunt fraction
  • Hospital Course
    • On HD # 3, the patient was intubated due to worsening pulmonary edema and to perform a TEE
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  • Hospital Course
    • After much deliberation on HD # 5, the patient went for surgical repair of the VSD
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  • Post – operative course
    • After the surgery, patient was extubated and IABP was discontinued on POD #1. After sedation was weaned, the patient continued to be confused and have delirium.
    • In addition, the patient had worsening renal and hepatic failure over the next tthree days.
  • Post – operative course
    • On POD #4, the patient became flaccid on his L side and had worsening of his cognitive function. Stroke team was called and the patient was taken for an MRI.
  • Ventricular Septal Rupture
    • Incidence
      • Before reperfusion therapy, septal rupture complicated 1 to 3 percent of acute myocardial infarction (AMI) 1
      • Reperfusion therapy decreases the incidence to 0.2 percent 2
    • Risk Factors
      • Before reperfusion era – hypertension, advanced age, female sex, absence of angina preceding MI
      • Reperfusion era – advanced age, female sex, absence of smoking
    1 Birnbaum, NEJM 2002 2 Crenshaw, Circulation 2000
  • The Evolution of an MI 7 - 10 d 3 - 4 d 30 m - 4 h 10 - 14 d 2 -8 wk Dense collagenous scar >2 mo Increased collagen deposition, with decreased cellularity 2–8 wk Well-established granulation tissue with new blood vessels and collagen deposition 10–14 days Well-developed phagocytosis of dead cells; early formation of fibrovascular granulation tissue at margins 7–10 days Beginning disintegration of dead myofibers, with dying neutrophils; early phagocytosis of dead cells by macrophages at infarct border 3–7 days Coagulation necrosis, with loss of nuclei and striations; brisk interstitial infiltrate of neutrophils 1 to 3 days Ongoing coagulation necrosis; myocyte hypereosinophilia; marginal contraction band necrosis; early neutrophilic infiltrate 12 to 24 hrs Early coagulation necrosis; edema; hemorrhage 4 to 12 hrs Variable waviness of fibers at border 30 min to 4 hrs Relaxation of myofibrils; glycogen loss; mitochondrial swelling 0 to 30 min Morphological Changes Time
    • Myocardial apoptosis associated with the expression of proinflammatory cytokines during the course of myocardial infarction FREE
    • Yoshikiyo Akasaka, Noriko Morimoto, Yukio Ishikawa, Kazuko Fujita, Kinji Ito, Masayo Kimura-Matsumoto, Shigeki Ishiguro, Hiroshi Morita, Yoshiro Kobayashi and Toshiharu Ishii
    • Mod Pathol 19: 588-598; advance online publication, March 3, 2006