Interesting-Didactic Cases Vasilios Papademetriou, MD VA Medical Center Washington DC

Vasilios Papademetriou, MD   Disclosures: I have no relevant financial relationships

AJ - Unusual presentation 68 YO M with DM, HTN, HLD, CKD-3 Drove to the ER at 9 am, feeling dizzy, c/o nausea/vomiting. Got out of the car and passed out in the parking lot ER personnel to the rescue ER, c/o N/V, lightheadedness, but no C/P. Thought had food poisoning BP 80/54 mmHg, P=110 ECG ?? Troponin in ER 2.3 Bedside echo shows inferolateral hypokinesis’ Overall LV function preserved. Patient denies h/o c/p, or h/o CAD Labs: Glucose 110 mg/dl, BUN/CR= 34/2.4, K=4.1, Na=141

AJ-ER ECG

AJ-8/2013

AJ-2-13-17

Case-1 JA

Mr-JA

Mr-JA

Mr-JA

Mr-JA

AJ-Next day 2-14-17 Moral: N/V can be lethal, need ECG Q: Large thrombus: Aspirate or just STENT Q: Just the Culprit or complete revascularization Good things are happening in Cardiology at the VA

Case-2, Mr-W Patient is 78 YO oriental male Admitted with chest pain and positive cardiac enzymes Serum troponin, 1.2 Initial cardiac cath showed : Occluded LCx, Collaterals from the left Occluded RCA, Collaterals from the left 90% proximal LAD EF 45%

Ecg at presentation

Mr W. diagnostic cardiac cath

Mr-W Patient admitted and schedule for by pass surgery the next day

Mr w At 2 AM patient taken for pre-op shower, and…. coded!!! Code blue called, CPR performed for 20 min, Patient intubated, stabilized, pulse palpable ECG significant for marked ST elevation/depression Acute MI team called for emergency PCI

Ecg after the code

Patient taken to the cath lab for revascularization Mr-W Patient taken to the cath lab for revascularization

Mr-W

Mr-W

Mr-W Patient did well, stabilized. Transferred to CCU, low dose dopamine, planning staged PCI next day

Mr-W

Mr-W

Taken to CCU in stable condition Mr-W Taken to CCU in stable condition

Post 3 vessel pci.2 days later Patient doing well

Mr-W Unfortunately the next day patient developed bleeding PUD and perforation! underwent surgical repair !!

Troponine -I

Serum Creatinine

Blood Pressure

Good things are happening at the VA Mr-W Patient did well, Discharged to home Pre-discharge echo, EF =45% Attends clinics regularly Very compliant to Meds Enjoys life Q: Is waiting a risk? Q: Severe 3V CABG? PCI? Good things are happening at the VA