NYU Medical Grand Rounds Clinical Vignette

Jacqueline Lonier, PGY2

November 3rd, 2010

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient is a 54 year old woman presenting with chest pain for one month.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•The patient’s history of present illness begins earlier the year of admission, when she was diagnosed with type II diabetes, hypertension, and hyperlipidemia.

•She was in her usual state of health until one month prior to admission, when she noted the development of substernal chest pain with exertion.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•Her chest pain progressively worsened, prompting her to present to an outside hospital.

•During her workup there, she underwent stress testing which was positive for ischemia.

•She was then transferred to Bellevue Hospital for further evaluation.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Past Medical History:•Hypertension•Hyperlipidemia•Type II diabetes

•Past Surgical History:•None

•Social History:•No history of tobacco, alcohol, or drug use•She is unemployed

•Family History:•No history of early coronary artery disease or diabetes

•Allergies: •No known drug allergies

•Medications:•Lisinopril 10 mg daily•Metoprolol 25 mg twice daily•Simvastatin 80 mg daily•Metformin 500 mg twice daily

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•General: Well-developed, well-nourished and in no acute distress

•Vital Signs: T 97.2, BP 110/70, HR 71, RR 16,

O2 sat 98% on room air

•The remainder of the physical exam was normal.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•CBC: within normal limits

•Basic Metabolic Panel: within normal limits

•Hepatic Panel: within normal limits

•Lipid Panel: Total Cholesterol 129 (<200), HDL 28 (38-92), LDL 68 (<130), Triglycerides 164 (55-250)

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

•Electrocardiogram: Normal sinus rhythm with T-wave flattening in V3-V6

•Chest X-Ray: no abnormalities

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Unstable angina

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 1:– The patient underwent cardiac

catheterization, which demonstrated 75% occlusion of the proximal left anterior descending artery, 80% occlusion of the distal left anterior descending artery, and 80% occlusion of the right coronary artery.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 1:– The patient was considered for enrollment in

the FREEDOM trial, a prospective randomized trial comparing the effectiveness of multivessel stenting using drug-eluting stents, to Coronary Artery Bypass Grafting in patients with diabetes mellitus and multivessel coronary artery disease.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 1:– The cardiology fellow informed the FREEDOM

trial coordinator about the results of the patient’s catheterization.

– The coordinator explained the trial to the patient and left the consent with the patient to be reviewed and read with family members.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 2:– The cardiovascular surgeons and

interventional cardiologists agreed that the patient was a study candidate.

– The patient agreed to be in the study and signed the consent, and was randomized to the percutaneous coronary intervention arm of the trial.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was discharged and was then electively re-admitted one month later for percutaneous coronary intervention.

• A drug-eluting stent was placed in the right coronary artery without complication.

Interim History

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was electively admitted a second time one month later. Drug-eluting stents were placed in the proximal and distal left anterior descending artery. The patient was discharged with outpatient follow-up.

Interim History

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Unstable angina secondary to multivessel coronary artery disease, due to multiple risk factors including hypertension, hyperlipidemia and type II diabetes mellitus.

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS