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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
  • Transcript

    • 1. CCU Case Conference
    • 2. 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
    • 3. 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.
    • 4. Past Medical History
      • PMH: HTN, borderline hyperlipidemia, psoriasis
      • Meds: on HTN meds which he did now the names that he took irregularly
      • ROS: negative
    • 5.
      • What were his cardiac risk factors?
    • 6.  
    • 7. South Asians and CV risk
    • 8. 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
    • 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
    • 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
    • 11. Laboratory Assessment
      • Troponins 12
      • CK
      • CK MB 24
      • BNP
    • 12.  
    • 13.  
    • 14.  
    • 15.  
    • 16.  
    • 17.  
    • 18.  
    • 19.  
    • 20. 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
    • 21. 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
    • 22. Hospital Course
      • On HD # 3, the patient was intubated due to worsening pulmonary edema and to perform a TEE
    • 23.  
    • 24.  
    • 25.  
    • 26.  
    • 27.  
    • 28.  
    • 29. Hospital Course
      • After much deliberation on HD # 5, the patient went for surgical repair of the VSD
    • 30.  
    • 31.  
    • 32. 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.
    • 33. 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.
    • 34. 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
    • 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
    • 36.
      • 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

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