CCU Case Conference
Chief Complaint <ul><li>45 yo Pakistani M with HTN, diet controlled hyperlipidemia, psoriasis presents with 5/10 midsterna...
History of Present Illness <ul><li>Patient’s pain began suddenly at 4:30 pm and was not exacerbated with exertion.  He too...
Past Medical History <ul><li>PMH:  HTN, borderline hyperlipidemia, psoriasis </li></ul><ul><li>Meds: on HTN meds which he ...
<ul><li>What were his cardiac risk factors? </li></ul>
 
South Asians and CV risk
Physical Exam <ul><li>Gen: Anxious, AOx3, NAD </li></ul><ul><li>VS: 98.9  108/81  103 reg  114  98% RA </li></ul><ul><li>6...
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 – ...
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...
Laboratory Assessment <ul><li>Troponins  12 </li></ul><ul><li>CK </li></ul><ul><li>CK MB 24 </li></ul><ul><li>BNP </li></ul>
 
 
 
 
 
 
 
 
Hospital Course <ul><li>Overnight, the patient remained tachycardic, but his blood pressure was stable.  The patient, howe...
Hospital Course <ul><li>On HD # 2,  a intra-aortic balloon pump was placed to improve the patient’s cardiac output.  Throu...
Hospital Course <ul><li>On HD # 3, the patient was intubated due to worsening pulmonary edema and to perform a TEE </li></ul>
 
 
 
 
 
 
Hospital Course <ul><li>After much deliberation on HD # 5, the patient went for surgical repair of the VSD </li></ul>
 
 
Post – operative course <ul><li>After the surgery, patient was extubated and IABP was discontinued on POD #1.  After sedat...
Post – operative course <ul><li>On POD #4, the patient became flaccid on his L side and had worsening of his cognitive fun...
Ventricular Septal Rupture <ul><li>Incidence </li></ul><ul><ul><li>Before reperfusion therapy, septal rupture complicated ...
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 dep...
<ul><li>Myocardial apoptosis associated with the expression of proinflammatory cytokines during the course of myocardial i...
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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
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    1. 1. CCU Case Conference
    2. 2. Chief Complaint <ul><li>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 </li></ul>
    3. 3. History of Present Illness <ul><li>Patient’s pain began suddenly at 4:30 pm and was not exacerbated with exertion. He took acetaminophen which offered no relief. </li></ul><ul><li>At 5:30 pm, the patient continued to have pain which prompted him to call the EMS. </li></ul>
    4. 4. Past Medical History <ul><li>PMH: HTN, borderline hyperlipidemia, psoriasis </li></ul><ul><li>Meds: on HTN meds which he did now the names that he took irregularly </li></ul><ul><li>ROS: negative </li></ul>
    5. 5. <ul><li>What were his cardiac risk factors? </li></ul>
    6. 7. South Asians and CV risk
    7. 8. Physical Exam <ul><li>Gen: Anxious, AOx3, NAD </li></ul><ul><li>VS: 98.9 108/81 103 reg 114 98% RA </li></ul><ul><li>65 in 202 lbs </li></ul><ul><li>HEENT: MMM </li></ul><ul><li>Neck: JVP around 8 cm </li></ul><ul><li>CV: Tachy, RRR systolic murmur III/VI at LLSB, RV heave </li></ul><ul><li>Lungs: b/l crackles at bases </li></ul><ul><li>Abd: Soft </li></ul><ul><li>Ext: Warm, 2+ pedal pulses, dry scaly skin at shins b/l </li></ul>
    8. 9. 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
    9. 10. 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
    10. 11. Laboratory Assessment <ul><li>Troponins 12 </li></ul><ul><li>CK </li></ul><ul><li>CK MB 24 </li></ul><ul><li>BNP </li></ul>
    11. 20. Hospital Course <ul><li>Overnight, the patient remained tachycardic, but his blood pressure was stable. The patient, however, did have increasing oxygen requirements. </li></ul><ul><li>He was started on nitroprusside to maintain a systolic blood pressure < 110 mmHg </li></ul>
    12. 21. Hospital Course <ul><li>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 </li></ul><ul><li>The following blood gases were drawn to meaure a shunt fraction </li></ul>
    13. 22. Hospital Course <ul><li>On HD # 3, the patient was intubated due to worsening pulmonary edema and to perform a TEE </li></ul>
    14. 29. Hospital Course <ul><li>After much deliberation on HD # 5, the patient went for surgical repair of the VSD </li></ul>
    15. 32. Post – operative course <ul><li>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. </li></ul><ul><li>In addition, the patient had worsening renal and hepatic failure over the next tthree days. </li></ul>
    16. 33. Post – operative course <ul><li>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. </li></ul>
    17. 34. Ventricular Septal Rupture <ul><li>Incidence </li></ul><ul><ul><li>Before reperfusion therapy, septal rupture complicated 1 to 3 percent of acute myocardial infarction (AMI) 1 </li></ul></ul><ul><ul><li>Reperfusion therapy decreases the incidence to 0.2 percent 2 </li></ul></ul><ul><li>Risk Factors </li></ul><ul><ul><li>Before reperfusion era – hypertension, advanced age, female sex, absence of angina preceding MI </li></ul></ul><ul><ul><li>Reperfusion era – advanced age, female sex, absence of smoking </li></ul></ul>1 Birnbaum, NEJM 2002 2 Crenshaw, Circulation 2000
    18. 35. 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
    19. 36. <ul><li>Myocardial apoptosis associated with the expression of proinflammatory cytokines during the course of myocardial infarction FREE </li></ul><ul><li>Yoshikiyo Akasaka, Noriko Morimoto, Yukio Ishikawa, Kazuko Fujita, Kinji Ito, Masayo Kimura-Matsumoto, Shigeki Ishiguro, Hiroshi Morita, Yoshiro Kobayashi and Toshiharu Ishii </li></ul><ul><li>Mod Pathol 19: 588-598; advance online publication, March 3, 2006 </li></ul>
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