NYU Medical Grand Rounds Clinical Vignette

Audrey Pendleton, MD

PGY2

November 29, 2011

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Patient is a 66 year-old man who presents with a one-day history of substernal chest pain

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

The patient was in his usual state of good health until 1996 when he developed progressive typical anginal symptoms and was diagnosed with multi-vessel coronary artery disease.

He underwent three-vessel coronary artery bypass graft.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Over several years, the patient had multiple re-admissions for typical chest pain in the setting of poor adherence to anti-platelet medications.

He was found to have 100% occlusive disease in two grafts and diffuse obstructive coronary disease in 2006.

In 2009, he underwent percutaneous coronary intervention with drug-eluting stents to the proximal left circumflex and obtuse marginal 2, and maintained on aspirin and clopidogrel.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Three months prior to presentation, he was admitted to an outside hospital for an upper gastrointestinal hemorrhage requiring blood transfusion.

A diagnostic upper endoscopy was performed showing evidence of chronic gastritis.

He was discharged in stable condition with instructions to discontinue aspirin and clopidogrel.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

The patient returned to his baseline of good health with unlimited exercise tolerance when on the morning of presentation while at rest, he developed substernal pressure-like chest pain, radiating to both shoulders and with associated dyspnea.

He took two sublingual nitroglycerin without relief, and subsequently called an ambulance and reported to an outside hospital.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

Past Medical History•Hypertension•Coronary Artery Disease•Peripheral Artery Disease•Diabetes Mellitus, Type 2•Chronic Kidney Disease, Stage 3•Gastritis, Upper Gastrointestinal Bleed

Past Surgical History•Three-vessel coronary artery bypass graft•Percutaneous coronary intervention with drug-eluting stents

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Family History•Mother: Died of myocardial infarction, age 80•Father: Died of myocardial infarction, age 70

•Social History•Tobacco: 22 pack year history, quit 16 years ago•Denies alcohol and illicit drugs

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Medications•Ramipril 2.5mg by mouth daily•Spironolactone 25mg by mouth daily•Furosemide 20mg by mouth daily•Atenolol 50mg by mouth twice daily•Amlodipine-Benazepril 5/50mg by mouth daily•Simvastatin 20mg by mouth at night•Lansoprazole 30mg by mouth daily

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•General: Well-appearing middle-aged man in no acute distress

•Vital Signs: list T:98.7 BP:155/90, HR:83, RR: 15, and O2 sat: 100%RA

•Physical exam was otherwise normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•CBC:•Hemoglobin-11.9 g/dl, hematocrit-35.9%

•Chemistries:•Cr 1.7mg/dl (normal 0.1-1.4mg/dl)•Troponin-15.5 ng/ml (normal <0.059ng/ml)•CK- 545 u/L (normal 45-245u/L)

•The remainder of the lab values were within normal limitsUNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

ECG: NSR at 80bpm, flattened T waves in I, aVL, and V6

CXR: normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Non-ST-elevation myocardial infarction

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 1:

• At the outside hospital he was treated with aspirin, clopidogrel, metoprolol, sublingual nitroglycerin, heparin drip and normal saline.

• The patient was then transferred to the Coronary Care Unit at Bellevue Hospital.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 2-3• The patient underwent transthoracic

echocardiogram which revealed a depressed EF of 40% and hypokinesis in the inferior and lateral walls.

• A cardiac catheterization was performed showing an acute 70% occlusive thrombus within the proximal left circumflex stent.

• The patient was changed from heparin to bivalirudin gtt.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 4 to Discharge• The patient underwent repeat coronary artery

catherization showing complete resolution of acute thrombus with an underlying 40% re-stenosis lesion within the proximal left circumflex artery stent.

• The patient remained stable without evidence of hemorrhage on anti-platelet agents.

• He was ultimately discharged home on aspirin and clopidogrel.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Non-ST-elevation myocardial infarction due to acute in-stent thrombosis in the setting of discontinued anti-platelet agents

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS