1. Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine http://clinicalcorrelations.org

2. Medical Grand Rounds Clinical Vignette December 17 th, 2008 Anjali Grover, M.D.

3. Chief Complaint A 45 year old Hispanic male presents with chest pain for 45 minutes.

4. History of Present Illness The patient was well until the evening of admission when he had the sudden onset of non-radiating, sub-sternal chest pressure while walking. The chest pain was associated with shortness of breath, light-headedness, palpitations, diaphoresis and nausea without vomiting.

5. Additional History Past Medical History: –Hyperlipidemia –Depression Past Surgical History: none Social history: –Current smoker with a 25 pack year history –Denies ethanol or illicit drug use Family History: –Mother died of a myocardial infarction at age 76 Allergies: –No known drug allergies Medications: -- Simvastatin 40 mg daily -- Aspirin 81 mg daily -- Fluoxetine 20 mg daily

6. Physical Exam General: In mild distress appearing anxious secondary to chest pain, appeared his stated age. T:97.1 o F BP:159/82 HR:84 RR:16 O:97%RA T:97.1 o F BP:159/82 HR:84 RR:16 O 2 :97%RA The remainder of the physical exam was normal

7. Laboratory Basic Metabolic Panel normal Complete Blood Count normal Hepatic Function Panel normal Time 0 hoursTime 8 hours Troponin0.09 (normal <0.07)0.01

8. Imaging ECG: Sinus rhythm with rate of 63, 2 mm ST elevation in V2, 1 mm up-slanting ST depression in II, III, aVf. Chest X-Ray: No evidence of pulmonary congestion, infiltrate or effusions.

9. Working Diagnoses Acute Coronary Syndome: ST Elevation Myocardial Infarction (STEMI) Brugada Syndrome

10. Hospital Course Emergency Room course: –Treated with: Aspirin 325mg Clopidogrel 300mg Lopressor 5 mg IVP x 3 Morphine 4mg IVP Sub-lingual Nitroglycerine 0.4mg x 3 Heparin drip Lipitor 80 mg The patient remained hemodynamically stable, EKG changes were stable and his chest pain resolved.

11. Hospital Course Hospital Day #1:   Cardiac Catheterization revealed clean coronary arteries   Transthoracic Echocardiogram showed no abnormalities Hospital Day #2:   Procainamide challenge performed to evaluate for possible manifestations of Brugada Syndrome on EKG.   With procainamide, the patient’s 2mm “saddle-back” ST segment elevation in V2 converted to a “coved” ST segment elevation pattern.   These findings represented a positive procainamide challenge.

12. Hospital Course Hospital Day #3:  Electrophysiology Study performed for further risk stratification revealed no inducible ventricular arrhythmias. Intracardiac defibrillator placement was recommended to the patient, but he refused. He was discharged on Aspirin and Zocor. 6 months later on follow-up in Cardiology Clinic, the patient agreed to ICD placement. It was placed shortly thereafter.

13. Final Diagnosis Type 2 Brugada Syndrome