acute transmural anterior wall myocardial infarction

NYU Medical Grand Rounds Clinical Vignette

Jeremy R. Beitler MD, PGY-2

December 16, 2009

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DEPARTMENT OF VETERANS

AFFAIRS

A 66-year-old man presents complaining of substernal chest and epigastric pain for thirty minutes.

Chief Complaint

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History of Present Illness

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• The patient was in his usual state of good health until thirty minutes prior to presentation in the emergency room.

• He reported a previously unlimited exercise tolerance.

• He denied having previous episodes of chest pain.

History of Present Illness

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• Thirty minutes prior to presentation, the patient noted the sudden onset of non-radiating substernal chest pressure while climbing a flight of stairs.

• The pain did not resolve with rest.

• The chest pain was associated with dyspnea, diaphoresis, epigastric discomfort and a single episode of vomiting.

• EMS was called. Aspirin 162mg was administered and the patient was brought to the Bellevue Hospital Emergency Room.

Additional History

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Past Medical History• Hypercholesterolemia

Past Surgical History• Appendectomy

Family History• Mother: Diabetes mellitus• Father: Emphysema

Social History• Lifetime non-smoker• Denies alcohol use• Denies illicit drug use

Outpatient Medications

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Aspirin 81mg Daily

Simvastatin 40mg QHS

No known allergies

Physical Examination

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General: Slightly pale and diaphoretic man in mild distress

Vitals: T 97.0F, BP 134/92, HR 55, RR 22

O2 saturation: 99% on room air

Cardiac: Non-displaced point of maximal impulse, no murmurs or rubs, no elevation of jugular venous pressure, 2+ distal pulses

Pulmonary: Clear to auscultation

Abdominal: Mild epigastric tenderness

The remainder of the physical exam was normal.

Initial Studies

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CBC: Within normal limits

Basic Metabolic Panel: Within normal limits

Hepatic Panel: Within normal limits

Troponin-I: 0.128 ug/dL (< 0.059 ug/dL)

CXR: Within normal limits

Electrocardiogram

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Working Diagnosis

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Non-ST Elevation Myocardial Infarction

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Hospital Course

• Fifteen minutes after arriving in the emergency room, the patient’s blood pressure fell to 80/30 mmHg. A 1 Liter bolus of normal saline was administered with return of a normal blood pressure.

• Due to the transient hypotension, the cardiology consult service was called to evaluate the patient.

• At the time of the cardiology consultant’s examination, the patient had developed diffuse bilateral rales. The ECG was interpreted as extensive anterior infarction with ongoing ischemia.

• The ST-elevation myocardial infarction team activated, and Clopidogrel 600mg and Atorvastatin 80mg were administered.

Hospital Course

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• The patient was taken emergently to the cardiac catheterization laboratory where diagnostic angiography demonstrated:

• Total occlusion of the proximal LAD with angiographic features consistent with acute thrombus

• 90% stenosis of the mid RCA

• During the procedure, the patient developed ventricular fibrillation. He was successfully defibrillated and maintained on lidocaine.

• Percutaneous coronary intervention was performed on the proximal LAD lesion with deployment of a drug-eluting stent.

• Door-to-Balloon Time: 70 Minutes

Hospital Course

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• The patient was admitted to the coronary care unit for observation and initiation of optimal medical therapy.

• Troponin measurements peaked at levels greater than 50 ug/dL.

• Transthoracic echocardiography demonstrated an LVEF of 33% with severe hypokinesis of the intraventricular septum, anterior walls and apical regions.

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Final Diagnosis

Acute Transmural Anterior Wall Myocardial Infarction

acute transmural anterior wall myocardial infarction

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