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

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

3. 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

4. AJ-ER ECG

5. AJ-8/2013

6. AJ

7. Case-1 JA

8. Mr-JA

9. Mr-JA

10. Mr-JA

11. Mr-JA

12. 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

13. 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%

14. Ecg at presentation

15. Mr W. diagnostic cardiac cath

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

17. 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

18. Ecg after the code

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

20. Mr-W

21. Mr-W

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

23. Mr-W

24. Mr-W

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

26. Post 3 vessel pci.2 days later Patient doing well

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

28. Troponine -I

29. Serum Creatinine

30. Blood Pressure

31. 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