Case Discussion Dr. Raid Jastania

A 65-year-old man presented to the emergency room with a recent (4-hour) history of severe chest pain radiating to his left arm. He was suspected to have had a "heart attack." Coronary angiography revealed a complete occlusion of the left anterior descending branch about 2 cm from its origin.

He was given a therapeutic dose of recombinant human tissue plasminogen activator (t-PA). This treatment restored coronary artery blood flow, and his chest pain improved. Simultaneously, he was started on one tablet of aspirin per day.

What therapeutic agent can be used to lyse the clots in coronary vessels? Why was aspirin given? What stage of hemostasis is affected by aspirin? What are natural anticoagulants?

What are the causes of arterial thrombosis?

What is the thrombus made of? What causes arterial thrombosis?...venous thrombosis What are the various fates of thrombi? Which of these fates is clinically most significant in the arterial circulation vs. the venous circulation?

Describe the morphology (microscopy) of myocardial infarction?

What are the major similarities between a myocardial and a cerebral infarct? What are the major differences between a myocardial and a cerebral infarct? What is the mechanism of formation of hemorrhagic infarcts in brain? What are the types of infarcts?

Seven days later, he noted swelling of both legs and feet and was found to have pitting edema of the legs; his liver was somewhat enlarged; and his neck veins (jugular) appeared full. He was given diuretics and asked to consume a salt-restricted diet. Because of considerable weakness, he remained in bed most of the time.

What caused enlargement of the liver, edema, and fullness of the neck veins in this patient?

What is the pathogenesis of pulmonary edema? How does this type of edema differ from that seen in acute inflammation?

Are the alveolar septa normal in thickness? What effect would such a histologic picture have on gaseous exchange in the lung? What might the symptoms be?

A few days later, he developed sudden pain in the lower right part of his chest, which was aggravated by taking a deep breath. Physical examination revealed that his left leg had developed more swelling than the right. X-ray of his chest showed a faint shadow in the peripheral part of the lower lobe of the right lung. Intravenous heparin was started. Two days later, he became very breathless and died suddenly.

Did this patient have clinical features suggestive of pulmonary thromboembolism? Why are some infarcts red and others pale? What is the most common symptom of pulmonary embolism? How and when does pulmonary thromboembolism cause sudden death? When does pulmonary thromboembolism result in infarction?

What conditions predispose to venous thrombosis? What is the most common source of clinically significant pulmonary emboli (ie, thrombi from which vessels in the leg)? What is the most common symptom associated with such venous thrombi?