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NYU Medical Grand Rounds Clinical Vignette

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

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Audrey Pendleton, MD PGY2 November 29, 2011 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Patient is a 66 year-old man who presents with a one-day history of substernal chest pain

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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.

  4. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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.

  5. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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.

  6. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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.

  7. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  8. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  9. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  10. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  11. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  12. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS ECG: NSR at 80bpm, flattened T waves in I, aVL, and V6 CXR: normal

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working Diagnosis • Non-ST-elevation myocardial infarction

  14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • 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.

  15. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • 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.

  16. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • 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.

  17. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Non-ST-elevation myocardial infarction due to acute in-stent thrombosis in the setting of discontinued anti-platelet agents

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