NYU Medical Grand Rounds Clinical Vignette Jennifer Lue, MD PGY-2 9/11/2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Mr. Y is a 64 year old Chinese Male who presents with chest pain for 24 hours. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

One day prior to presentation, the patient began to experience 8/10, non-radiating, substernal chest pressure associated with diaphoresis and shortness of breath. The pain initially improved with Tylenol, however over the following 24 hours, his symptoms worsened The patient went to his primary physician, where an EKG was performed which showed ST elevations in leads V2-V6. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

He was given Aspirin 325mg and Nitroglycerine spray and his symptoms improved. EMS was called and the patient was taken to the Bellevue ER where a STEMI alert was called History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Additional History Past Medical History: Osteoarthritis Past Surgical History: None Social History: Denies tobacco, alcohol and other illicit drug use Family History: Denies early MI, sudden cardiac death, DM, HTN, HLD No Known Drug Allergies Medications: None U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Physical Examination General: Chinese Male, laying in a stretcher, in mild distress Vital Signs: T: 98.6 BP:106/76 HR:67 RR:18 and O2 sat:100% on 2L NC Remainder of the physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings CBC: WBC 10.9 (77% neutrophils) Remainder of CBC was within normal limits Basic Metabolic panel: within normal limits Hepatic panel: AST 252, ALT 52 Remainder of hepatic panel was within normal limits INR, PT, PTT within normal limits Troponin >50 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

ECG: Normal Sinus Rhythm, Normal axis. Q w in I, avL, V2-V6. ST elevations in V2-V6.

Other Studies Chest X-Ray: no infiltrates, effusions, consolidations U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Working Diagnosis Acute Coronary Syndrome ST Elevation Myocardial Infarction

Hospital Day 1: –The patient was started on Plavix 75mg, ASA 81mg, Crestor 40mg –Cardiac Catherization demonstrated a complete occlusion of mid- Left Anterior Descending Artery, with a 50% proximal Right Coronary Artery lesion. Drug Eluting Stent was placed in mid Left Anterior Descending Artery –A transthoracic echocardiogram showed an ejection fraction of 30%, apical anterior wall akinesis, apical lateral wall akinesis, dyskinesis of LV apex and apical septum akinesis. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hospital Day 1 cont. –Due to a depressed ejection fraction and significant anterior wall hypokinesis, the patient was started on heparin drip and bridged to coumadin Hospital Day 2-3 –The patient was started on metoprolol succinate 25mg daily and lisinopril 2.5mg daily Hospital Day 4 –The patient was discharged home Hospital Course

ST Elevation Myocardial Infarction Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS