1. NYU Medical Grand Rounds Clinical Vignette Audrey Pendleton, MD PGY2 November 29, 2011 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. Patient is a 66 year-old man who presents with a one-day history of substernal chest pain Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient was in his usual state of good health until 1996 when he developed progressive typical anginal symptoms and was diagnosed with multi-vessel coronary artery disease. He underwent three-vessel coronary artery bypass graft. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Over several years, the patient had multiple re-admissions for typical chest pain in the setting of poor adherence to anti-platelet medications. He was found to have 100% occlusive disease in two grafts and diffuse obstructive coronary disease in 2006. In 2009, he underwent percutaneous coronary intervention with drug-eluting stents to the proximal left circumflex and obtuse marginal 2, and maintained on aspirin and clopidogrel. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Three months prior to presentation, he was admitted to an outside hospital for an upper gastrointestinal hemorrhage requiring blood transfusion. A diagnostic upper endoscopy was performed showing evidence of chronic gastritis. He was discharged in stable condition with instructions to discontinue aspirin and clopidogrel. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. The patient returned to his baseline of good health with unlimited exercise tolerance when on the morning of presentation while at rest, he developed substernal pressure-like chest pain, radiating to both shoulders and with associated dyspnea. He took two sublingual nitroglycerin without relief, and subsequently called an ambulance and reported to an outside hospital. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Additional History Past Medical History Hypertension Coronary Artery Disease Peripheral Artery Disease Diabetes Mellitus, Type 2 Chronic Kidney Disease, Stage 3 Gastritis, Upper Gastrointestinal Bleed Past Surgical History Three-vessel coronary artery bypass graft Percutaneous coronary intervention with drug-eluting stents U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Additional History Family History Mother: Died of myocardial infarction, age 80 Father: Died of myocardial infarction, age 70 Social History Tobacco: 22 pack year history, quit 16 years ago Denies alcohol and illicit drugs U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Additional History Medications Ramipril 2.5mg by mouth daily Spironolactone 25mg by mouth daily Furosemide 20mg by mouth daily Atenolol 50mg by mouth twice daily Amlodipine-Benazepril 5/50mg by mouth daily Simvastatin 20mg by mouth at night Lansoprazole 30mg by mouth daily U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Physical Examination General: Well-appearing middle-aged man in no acute distress Vital Signs: list T:98.7 BP:155/90, HR:83, RR: 15, and O2 sat: 100%RA Physical exam was otherwise normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Laboratory Findings CBC: Hemoglobin-11.9 g/dl, hematocrit-35.9% Chemistries: Cr 1.7mg/dl(normal 0.1-1.4mg/dl) Troponin-15.5 ng/ml (normal <0.059ng/ml) CK- 545 u/L (normal 45-245u/L) The remainder of the lab values were within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Other Studies ECG: NSR at 80bpm, flattened T waves in I, aVL, and V6 CXR: normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Non-ST-elevation myocardial infarction Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Hospital Day 1: At the outside hospital he was treated with aspirin, clopidogrel, metoprolol, sublingual nitroglycerin, heparin drip and normal saline. The patient was then transferred to the Coronary Care Unit at Bellevue Hospital. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Hospital Day 2-3 The patient underwent transthoracic echocardiogram which revealed a depressed EF of 40% and hypokinesis in the inferior and lateral walls. A cardiac catheterization was performed showing an acute 70% occlusive thrombus within the proximal left circumflex stent. The patient was changed from heparin to bivalirudin gtt. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. Hospital Day 4 to Discharge The patient underwent repeat coronary artery catherization showing complete resolution of acute thrombus with an underlying 40% re-stenosis lesion within the proximal left circumflex artery stent. The patient remained stable without evidence of hemorrhage on anti-platelet agents. He was ultimately discharged home on aspirin and clopidogrel. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

17. Non-ST-elevation myocardial infarction due to acute in-stent thrombosis in the setting of discontinued anti-platelet agents Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS