A 48-year-old man presents to the emergency room agitated after abusing cocaine. His heart rate is 110 per minute, his BP is 200/120 mmHg, and an ECG shows ST elevation in the inferior leads. On examination he is diaphoretic with clear lung sounds. Auscultation is pertinent for a diastolic murmur at the base of the heart that accentuates with expiration.
What is the appropriate next step for definitive diagnostic evaluation?
Performance of a gated CT of the aorta. This patient has acute aortic regurgitation and performance of gated CT aorta is urgently indicated. Development of a new diastolic murmur at the base of the heart that accentuates with expiration should raise suspicion of acute aortic regurgitation. Acute aortic regurgitation is usually secondary to endocarditis or acute ascending aortic dissection. Ascending aortic dissection can involve the coronary cusps leading to acute coronary dissection that can present with chest pain and ST elevations on ECG. Cocaine use is a major risk factor for acute aortic dissection. While nongated CT with pulmonary embolus protocol can often detect acute aortic detection, it is often associated with motion artifacts in the aortic root and is not the ideal test. The patient has a suspected acute aortic dissection, and activation of catheterization laboratory for revascularization or antiplatelet therapy is not indicated. Confirmation by the performance of a CT aorta followed by immediate surgical consultation appears warranted. While two-dimensional echo can often detect an aortic dissection flap, absence of the same does not rule out aortic dissection.
A 78-year-old man calls 911 because he has sudden-onset chest pain. On EMS arrival he has a BP of 120/80 mmHg and a heart rate of 80 beats per minute. His lungs are clear to auscultation and he has a left ventricular (LV) S4 noted. ECG done on the field confirms an anterior MI with ST elevation from V1 to V4 . He is given an aspirin and a sublingual nitroglycerin and transfer is initiated. Within 5 minutes while en route his BP is noted to be 60 mmHg and a saline bolus is initiated. Cardiovascular examination is unchanged and no murmurs are noted.
Which of the following scenarios may likely explain his observed hemodynamic deterioration?
Recent exposure to a phosphodiesterase 5 inhibitor. This patient developed immediate hypotension after administration of nitroglycerin. Administration of nitrates in patients who have recently taken phosphodiesterase 5 inhibitors such as sildenafil acetate can lead to severe hypotension, circulatory collapse, and death. The patient is unlikely to develop massive hemorrhage within 5 minutes of aspirin load, and anaphylaxis in this setting is extremely uncommon. Administration of nitrates can cause profound hypotension in RV infarction but this patient has ST elevations in V1 to V4 , suggesting anterior-apical wall MI.
A 42-year-old mother is visiting her child who is undergoing chemotherapy in the Children’s Hospital. She suddenly develops chest pain and is noted to be nauseous and diaphoretic. An ECG is performed (Fig. below). On angiography, the coronaries are free of significant epicardial stenosis. A ventriculogram shows apical ballooning with an LVEF of 25%. The patient is admitted to the CCU.
Which of the following statements will most likely define her clinical course?
Her prognosis will likely be excellent with full recovery of LV function. This patient has Takotsubo cardiomyopathy, also known as transient apical ballooning syndrome. This transient weakening of LV apex is often triggered by emotional stress, such as the death of a loved one, a breakup, or constant anxiety, and is most often seen in middle-aged women. Most patients achieve complete recovery within few months. There is no indication for ICD and there is no increased risk of atherosclerosis or malignancy. Routine anticoagulation with warfarin is not indicated in the absence of apical thrombus.
A 91-year-old man with a history of prior CABGx2 is brought from the nursing home with shortness of breath and hypotension. He is debilitated and has required 24/7 nursing care for activities of daily living. His ECG shows diffuse ST-segment depression, and he is noted to be in pulmonary edema. His heart rate is 110 per minute and his BP is 70/40 mmHg. He has a recent stroke 3 months prior and has stage 4 chronic kidney disease. History is also relevant for a diagnosis of prostate cancer with extensive metastasis to his spine.
Which of the following is indicated?
Discussion with the family explaining his poor prognosis and the near futility of escalating care is the ideal next step in this scenario. The patient presents with acute STEMI complicated by cardiogenic shock. The large randomized SHOCK trial did not show any benefit for a revascularization strategy in patients >75 years with cardiogenic shock. Data from multiple registries suggest that aggressive measures (IABP, heart catheterization, and revascularization) should be considered in patients with good baseline functional status, and such efforts are likely to be futile in this patient with poor functional status, extensive history of coronary artery disease, and multiple medical comorbidities.
A 64-year-old man presents with ST elevation and is taken for primary angioplasty (see Fig. below).
Identify the infarct-related artery?
Diagonal. The culprit infarct-related artery is the diagonal branch of LAD.
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