Acute Transmural Anterior Wall Myocardial Infarction

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  • MRN 3327176 “ Predictive Instruments for Acute Cardiac Care: Decision Aids to Supplement Clinical Art” Harry Selker, MD, MSPH, Tufts Univ School of Medicine Dean of the Tufts Clinical and Translational Science Institute Executive Director of the Institute for Clinical Research and Health Policy Studies Director of the Center for Cardiovascular Health Services Research
  • Initial EKG Reading: Sinus with PACs. Q waves in precordial leads. J-point elevation versus questionable hyperacute T waves in precordial leads with few reciprocal changes appreciated.
  • Acute Transmural Anterior Wall Myocardial Infarction

    1. 1. NYU Medical Grand Rounds Clinical Vignette Jeremy R. Beitler MD, PGY-2 December 16, 2009 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    2. 2. Chief Complaint A 66-year-old man presents complaining of substernal chest and epigastric pain for thirty minutes. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    3. 3. History of Present Illness <ul><li>The patient was in his usual state of good health until thirty minutes prior to presentation in the emergency room. </li></ul><ul><li>He reported a previously unlimited exercise tolerance. </li></ul><ul><li>He denied having previous episodes of chest pain. </li></ul>U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    4. 4. History of Present Illness <ul><li>Thirty minutes prior to presentation, the patient noted the sudden onset of non-radiating substernal chest pressure while climbing a flight of stairs. </li></ul><ul><li>The pain did not resolve with rest. </li></ul><ul><li>The chest pain was associated with dyspnea, diaphoresis, epigastric discomfort and a single episode of vomiting. </li></ul><ul><li>EMS was called. Aspirin 162mg was administered and the patient was brought to the Bellevue Hospital Emergency Room. </li></ul>U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    5. 5. Additional History <ul><li>Past Medical History </li></ul><ul><ul><li>Hypercholesterolemia </li></ul></ul><ul><li>Past Surgical History </li></ul><ul><ul><li>Appendectomy </li></ul></ul><ul><li>Family History </li></ul><ul><ul><li>Mother: Diabetes mellitus </li></ul></ul><ul><ul><li>Father: Emphysema </li></ul></ul><ul><li>Social History </li></ul><ul><ul><li>Lifetime non-smoker </li></ul></ul><ul><ul><li>Denies alcohol use </li></ul></ul><ul><ul><li>Denies illicit drug use </li></ul></ul>U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    6. 6. Outpatient Medications <ul><li>Aspirin 81mg Daily </li></ul><ul><li>Simvastatin 40mg QHS </li></ul><ul><li>No known allergies </li></ul>U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    7. 7. Physical Examination General : Slightly pale and diaphoretic man in mild distress Vitals : T 97.0F, BP 134/92, HR 55, RR 22 O 2 saturation : 99% on room air Cardiac : Non-displaced point of maximal impulse, no murmurs or rubs, no elevation of jugular venous pressure, 2+ distal pulses Pulmonary : Clear to auscultation Abdominal : Mild epigastric tenderness The remainder of the physical exam was normal. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    8. 8. Initial Studies CBC: Within normal limits Basic Metabolic Panel : Within normal limits Hepatic Panel: Within normal limits Troponin-I: 0.128 ug/dL (< 0.059 ug/dL) CXR: Within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    9. 9. Electrocardiogram U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    10. 10. Working Diagnosis Non-ST Elevation Myocardial Infarction U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    11. 11. Hospital Course <ul><li>Fifteen minutes after arriving in the emergency room, the patient’s blood pressure fell to 80/30 mmHg. A 1 Liter bolus of normal saline was administered with return of a normal blood pressure. </li></ul><ul><li>Due to the transient hypotension, the cardiology consult service was called to evaluate the patient. </li></ul><ul><li>At the time of the cardiology consultant’s examination, the patient had developed diffuse bilateral rales. The ECG was interpreted as extensive anterior infarction with ongoing ischemia. </li></ul><ul><li>The ST-elevation myocardial infarction team activated, and Clopidogrel 600mg and Atorvastatin 80mg were administered. </li></ul>U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    12. 12. Hospital Course <ul><li>The patient was taken emergently to the cardiac catheterization laboratory where diagnostic angiography demonstrated: </li></ul><ul><ul><li>Total occlusion of the proximal LAD with angiographic features consistent with acute thrombus </li></ul></ul><ul><ul><li>90% stenosis of the mid RCA </li></ul></ul><ul><li>During the procedure, the patient developed ventricular fibrillation. He was successfully defibrillated and maintained on lidocaine. </li></ul><ul><li>Percutaneous coronary intervention was performed on the proximal LAD lesion with deployment of a drug-eluting stent. </li></ul><ul><li>Door-to-Balloon Time: 70 Minutes </li></ul>U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    13. 13. Hospital Course <ul><li>The patient was admitted to the coronary care unit for observation and initiation of optimal medical therapy. </li></ul><ul><li>Troponin measurements peaked at levels greater than 50 ug/dL. </li></ul><ul><li>Transthoracic echocardiography demonstrated an LVEF of 33% with severe hypokinesis of the intraventricular septum, anterior walls and apical regions. </li></ul>U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
    14. 14. Final Diagnosis Acute Transmural Anterior Wall Myocardial Infarction U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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