A 59 year-old man suffered from persistent chest pain for
14 hours
Brief
History This 59 year-old man is a case of hypertension
noted for 20 years without regular control. He suffered
from intermittent precordial discomfort for about one year.
It was located over precordial area with radiation to back
and was associated with cold sweating. The symptom could be
triggered by exercise and be relieved by resting. In recent
one month, the frequency of chest pain increased. He suffered
from persistent chest pain at 2 am on June 13, 2000 with
little improved by sublingual nitroglycerin. On consulting our
ER that morning, ECG showed old inferior wall myocardial
infarction and inverted T over III, V4-6. Cardiac enzyme
elevation was also noted. Echocardiography at ER showed
hypokinesia over posterior, inferior, lateral, and apical
regions with LVEF about 20 %. Intravenous nitroglycerin was
administered but chest pain persisted. Under the impression of
acute non-Q MI, he was admitted to our CCU for further
evaluating and management.
Physically, he was illness looking in general with clear
consciousness. Blood pressure was 132/72 mmHg. Pulse was
regular at the rate of 86/ min. Body temperature was 36.6 °C.
Respiratory rate was 20 /min. Conjunctiva was not pale. Sclera
was not yellowish. Neck was supple without jugular vein
engorgement, carotid bruit, or lymphadenopathy. The chest wall
was symmetric without deformity. On auscultation, there were
bilateral basal crackles and mild wheezing. A grade II/VI
pan-systolic grade murmur was noted over left sternal border
and apex with radiation to axilla. There was no gallop nor
opening snap. Liver was palpable about 1 finger below right
cost margin. No abdominal tenderness or rebound pain
was noted. There was no leg pitting edema. Peripheral
pulses were symmetric.
Laboratory Findings:
1. CBC :
|
WBC (/μl) |
Hb (g/dl) |
MCV (μl) |
Plt (k/μl) |
Ret (%) |
6/13 |
7570 |
10.8 |
91 |
221 |
1.44 |
2. BCS:
|
Alb/Glo (g/dl) |
Bil(T/D) (mg/dl) |
ALP (U/l) |
GOT/GTP (U/l) |
r-GT (U/l) |
LDH (U/l) |
BUN/Cr (mg/dl) |
TG/Chol (mg/dl) |
6/13 |
3.3/3.1 |
0.7/0.2 |
131 |
138/39 |
39 |
1045 |
23/1.6 |
183/176 |
LDL-C : 103, HDL-C : 36 mg/dl
3. Electrolyte:6/13 Na: 138 mM; K: 3.3
mM; Ca: 2.15 mM
4. Others :
Ferritin: 65.3, Iron : 48, TIBC : 270; HbA1C
: 5.3 %; 24 hr CCr : 67 ml/min
5.
PPT:
Heparin(U/d) : |
15000(D1-2) |
30000(D2-6) |
35000(D7-8) |
PPT : |
39.1/37.8 |
38.3/38.6 |
60/32.4 |
TT :
unclot
|
6. ECG : III, aVf Q
wave, V4-6 inverted T wave, suggesting old inferior wall
infarction and lateral wall ischemia
7. EChocardiography :
Dilated LV with regional wall motion abnormalities
over 3 vessels territories, esp. right and left circumflex
regions. LVEF 0.20 (by area length). Dilated ascending aorta.
Mild MR.
Clinical Course &
Treatment : After admission, nitroglycerin
was titrated till chest pain relief. However, the PTT
was refractory despite increasing heparin dosage upto 35,000 U
per day. TT showed unclot. Low molecular weight
heparin (Fractionated heparin) was used since 6/20 in place
of heparin. Dobutamine (2.7 μg/kg/min), diuretics
and ACE-inhibitor were used. Iron was supplied for IDA. Gouty
pain was controlled by anti-inflammatory agent. Amiodarone
was used for frequent VPC. Stress echocardiography showed
ischemic myocardium over left circumflex area. The schedule
for percutaneous balloon coronary angioplasty was postponed by
hematemesis which occurred on 6/21 morning. |