1. NYU Medical Grand Rounds Clinical Vignette Ramin S Hastings, MD PGY-3 September 8, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 47 year old male presents with chest pain for two days Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. Mr. R is a 47 year old male with asthma and hypertension who was in his usual state of good health with a baseline exercise tolerance of fifteen blocks, until two days prior to admission when he developed new onset chest pain while lying down before going to bed. The patient stated the pain was a substernal pressure, as if “someone was trying to push my heart through my back.” The pain was non-radiating, and associated with mild shortness of breath, nausea, and diaphoresis. It resolved on its own after ten minutes. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. He went to sleep, and the following day was free of symptoms until that night when a similar attack of chest pain occurred, again lasting about ten minutes. On the day of admission he was at work, again not exerting himself, when he developed similar chest pain. The pain lasted fifteen minutes, and he was drenched in sweat. He then decided to present to the emergency room for care. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. On arrival to the emergency room, he was chest pain free, without complaint History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Additional History Past Medical History: Asthma – diagnosed in childhood, never intubated, approximately two exacerbations per year Hypertension – diagnosed 5 years ago poorly controlled Past Surgical History: Right hand fracture repair after motor vehicle accident (10 years ago) Social History: Smokes one to two packs of cigarettes per day for the past 30 years, previously heavy alcohol and cocaine abuse, quit three years ago Currently homeless and living in a shelter, works at a deli Family History: Adopted and does not know family history well Allergies: No known drug allergies Medications: Albuterol metered dose inhaler, 2 puffs as needed Fluticasone 220 mcg 1 puff every 12 hours Nifedipine 30 mg three times a day (however patient was not taking) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Physical Examination General: Obese African American male lying in stretcher in no acute distress Vital Signs: T: 97.1 BP: 198/112 HR: 94 RR: 16 and O2 sat: 98% Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Laboratory Findings CBC: White Blood Cell Count 11.5 Remainder of CBC was within normal limits Basic Metabolic panel: Glucose 106 Remainder of basic was within normal limits Hepatic panel: within normal limits Troponin 0.170 (normal 0.08) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Initial EKG U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Other Studies Electrocardiogram: Normal sinus rhythm at 70 beats per minute, normal axis, normal intervals, T-wave inversions in leads II/III/Avf and V3-V6, Left Ventricular Hypertrophy, no ST segment changes Chest X-Ray: no consolidations, no pulmonary edema U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Acute coronary syndrome Demand ischemia in the setting of uncontrolled hypertension Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Hospital Day 1: –Patient was started on aspirin, clopidogrel, heparin, and simvastatin –His blood pressure was controlled with calcium channel blockers –Trans-thoracic echocardiogram was performed showing: Concentric left ventricular hypertrophy Normal left ventricular ejection fraction Normal left ventricular wall motion Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Hospital Day 2: – Nuclear pharmacologic stress test was performed showing: No evidence of vasodilator-induced ischemia or decreased coronary artery flow reserve No evidence of prior myocardial infarction Normal wall motion and thickening with left ventricular ejection fraction of 54% –Given the normal echocardiogram and stress test the plan was to obtain a coronary computerized tomography angiography on the following day Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Hospital Day 3: –The patient had been chest pain free until this day, when he developed severe chest pain much like his prior episodes –Electrocardiogram was repeated Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Repeat EKG U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. Hospital Day 3 Continued: –He was treated with nitroglycerin with relief of the pain and normalization of the findings on electrocardiogram –He was admitted to the Coronary Care Unit and emergently brought to the catheterization laboratory Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

17. Cardiac Catheterization U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

18. Hospital Day 3 Continued: –Cardiac catheterization revealed: A 90% lesion was noted in the proximal left anterior descending artery A Promus stent was placed –Post-catheterization care was performed in the coronary care unit where he remained chest pain free Hospital Day 5: –The patient was discharged from the hospital Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

19. Atherosclerotic heart disease with acute coronary syndrome Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS