| A 58 year old male
presents to the ER with chest pain.
PAST MEDICAL HISTORY:
1. Coronary disease.
2. Cocaine abuse.
3. Questionable history of emphysema.
4. The patient has chronic joint pain problems.
FAMILY HISTORY:
Positive for hypertension.
His brother died of a heart attack at age 45.
- SOCIAL HISTORY:
- The patient lives in the
country. He has worked at odd jobs most of his life,
working in farming. He has a smoking habit, currently of
4-5 cigarettes a day, more in the past. He smokes crack
cocaine on a weekly basis; although he indicates that he is
trying to cut back. He does not have any history of
alcohol abuse or significant use.
Hospital Course: On June 4, 2003 a
58-year-old African-American gentleman with history of emphysema
was transferred from another hospital with dynamic EKG changes
and chest pain that occurred four to five hours
prior to presentation, did not really subside with rest, which
usually subsides the patient's pain. The patient admitted cocaine
use five days prior to presentation. The patient also admitted to
increased
chest pain episodes and shortness of breath on exertion for three
to four weeks.
The patient
was admitted to the CCU. He was started on Integralin,
aspirin, Simvastatin. Beta blocker was held due to cocaine use.
The patient was taken to the cath lab on 6/5/03, which showed
disease in the left circumflex, mid 60% in the large thrombus.
The patient received PCI stenting to the mid left circumflex and
OM III. LV-gram showed a 30% EF with severe lateral hypokinesis.
Decadron was continued post procedure for 18 hours. He was also
started on Plavix. The patient's troponin peaked at 166 and then
trended downward afterward. Echo was done to reevaluate bilateral
function, showing an EF of 30%. On 6/6/03 Amlodipine was added in
an effort to decrease coronary spasm. It was decided to hold beta
blocker due to patient's cocaine use and due to patient's very low
blood pressure no ACE inhibitor was started at this time with
plans to start at some point in the future as an outpatient. The
patient was transferred to Team One cardiology and remained
stable. He was discharged on 6/9/03.
Lab Values: Cardiac injury panel
| Test |
Test Result |
Range |
Units |
| CK, Total |
3201 |
50-260 |
IU/L |
| CK-MB |
280 |
0.2-5 |
ng/ml |
| CK- Relat.Index |
8.8 |
0-2.4 |
|
| Troponin I |
166 |
0-1.4 |
ng/ml |
The patient returned to the hospital on August 17th. He has
been unable to afford refills of his medications and thus has not
been on any medicines for months. The patient also has
history of crack cocaine abuse and continues his habit even after
multiple warnings as to the adverse effects on his coronary
disease that this would invoke. The patient had smoked crack
cocaine the day before presentation and had experienced substernal
chest pain with typical angina symptoms the afternoon and evening
before the morning of presentation. His symptoms did not
improve and seemed to get worse. He had associated nausea
and vomiting with shortness of breath. The patient presented
to the ER and was given nitroglycerine with some relief of pain.
The patient was admitted to the CCU service. He was put on
oxygen and serial cardiac enzymes were ordered. He was
started on a heparin drip in addition to Plavix and aspirin.
He was not started on a beta blocker due to his history of cocaine
use and his heart rate and blood pressure were actually within
good parameters. He had lipid studies and was started on a
statin. He was given no additional nitroglycerin or morphine
as the patient did not have recurrent chest pain during
hospitalization. Urine drug screen was positive for cocaine.
The cardiology service recommended coronary angiogram the
following day. The patient however did not want to have any
invasive testing particularly anything such as an angiogram.
Due to the patient's history of problems with affording
medications and general social problems including illicit drug
use, a social worker was contacted for assistance in helping this
patient get medical assistance and into some kind of drug
rehabilitation program. The patient did seem interested in
drug abuse treatment and was given extensive information on
possible treatment programs that he could enroll himself in by our
social worker. The patient continued to refuse invasive
testing, but did consent to a nuclear medicine stress test.
Nuclear Medicine
IV Persantine Stress. The resting ECG showed sinus rhythm
with T-wave abnormalities. Resting heart rate was 59 bpm and blood
pressure was 82/62. Following Persantine injection, the heart rate
was 75 bpm and blood pressure was 84/50. The patient complained of
shortness of breath, but denied any chest pain. There were no
significant ST changes over baseline.
IMPRESSION: NORMAL HEART RATE RESPONSE TO IV PERSANTINE WITHOUT
SIGNIFICANT ST CHANGES OVER BASELINE. THE PATIENT DID COMPLAIN OF
SHORTNESS OF BREATH DURING THE EXAM.
 |
For image magnification click on
image below |
Myocardial Perfusion Study with SPECT. 10.8 mCi of 99m Tc
Sestamibi was infused at rest. SPECT images of the myocardium were
obtained at approximately one hour delay. Subsequently, 39 mg of
IV Persantine were infused over four minutes for pharmacological
stressing. Seven minutes into the Persantine Stress Test, the
patient was injected with 31.8 mCi of 99m Tc Sestamibi, and the
imaging sequence was repeated.
- A large fixed perfusion defect is
seen involving the entire lateral wall, the anterolateral wall,
distal anterior wall, apex, and inferolateral wall. This is
primarily fixed. There may be a very small amount of reversibility
involving the anterior wall. The septal wall is the only normal
appearing wall. A Thallium viability study is recommended to
evaluate if any of this myocardium might, in fact, be hibernating.
(not performed)
IMPRESSION: LARGE FIXED PERFUSION DEFECT INVOLVING THE LATERAL,
INFERIOR, APEX, INFEROLATERAL WALLS. A THALLIUM VIABILITY IS
RECOMMENDED TO EVALUATE FOR HIBERNATING MYOCARDIUM. THE PATIENT'S
PHYSICIAN WAS NOTIFIED OF THESE RESULTS.
Quantitative gated SPECT: Quantitative gated SPECT study
was performed during the stress acquisition. The end diastolic
volume was calculated at 180cc. The end systolic volume was
calculated at 148cc. The left ventricular ejection fraction was
calculated at 18 percent. there is dyskinesis involving the apex
on the CINE images.
IMPRESSION: DILATED LEFT VENTRICULAR WITH SEVERE GLOBAL
HYPOKINESIS
AND DYSKINESIS OF THE APEX, WITH AN EJECTION FRACTION OF 18
PERCENT.
The patient was discharged after three days
displaying no recurrent pain or other angina-like symptoms.
The patient was discharged in stable condition with cardiac diet
and advised to limit activity to non-stressful activities for the
next month. He was also strongly advised to stay away from drugs
of abuse and to enroll himself in a drug treatment program.
The patient was also started on lisinopril at 10 mg p.o. q.d. in
addition to other medicines.
MEDICATIONS ON DISCHARGE:
1. Zocor 20 mg p.o. q.d.
2. Lisinopril 10 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Plavix 75 mg p.o.q.d.
5. Spironolactone 25 mg p.o.q.d.
- 6. Nitroglycerin SL prn
Four days following the discharge of the patient he presented
himself to the ER because of some difficulty breathing and
swallowing and was found to have angioedema of the uvula and
bottom lip. He presented with complaints of lip swelling
x 1 day. He denies chest pain, diaphoresis. He had a small
amount of cocaine on the day prior to admission. He was admitted to observation, and given IV Benadryl as
well as H2 Cimetidine p.o. q.8h. He was started on hydrocortisone
and had one administration of epinephrine. HIs shortness of
breath and difficulty swallowing subsided. It was believed
that he experienced an allergic reaction to the Lisinopril. The patient was discharged the
following day after evaluation by internal medicine. Patient was
without complaints, and instructed not to continue the ace
inhibitor at this point, and once again instructed on the
importance of cessation of cocaine.
Only four days following his last admission, the patient was once
again admitted. On the day of this admission the patient elapsed
and was unresponsive. MEMS was called and shocked the patient by
EED. The patient was shocked six times, and then started on
Lidocaine 100mg IV and brought to the MICU at UAMS. He was sedated
and intubated on arrival. Aspiration pneumonitis was suspected and
the patient was started on Clindamycin and Cefepime. Chest x-ray
later showed left lower lobe infiltrate. The patient continued to
spike temperatures and his white continued to increase. The
patient was started on aspirin, Plavix, heparin, and IV Amiodarone
was loaded. The Infectious Disease team saw the patient and recommended starting gatifloxacin, vancomycin, and Imipenim and stopping the
Clindamycin and the Cefepime because they felt that, because of
the patient's recent hospitalization, he would be treated for
noscomial organisms as well. The patient was started on vancomycin
and imipenem IV, but gatifloxacin was held because it has an
interaction with Amiodarone.
An echocardiogram was repeated and showed
that the EF had improved to 30-35%. The patient continued to
improve on the IV antibiotics and became afebrile. The white count
started to decrease. His hemoglobin and hematocrit was noted to be
low but stable. Social work was consulted and discussed plans to
go to a rehab unit with the patient. However, the patient became
evasive and did not wish to be sent to a rehab unit. The patient
also refused an IV line and IV antibiotics had to be stopped.
Therefore, he was started on 400 mg q.d. of p.o. gatifloxacin for
seven more days.
The patient contacted his family and was discharged 14 days
after his admission. The patient was given two follow up
appointments and also instructed concerning his medications. The
patient was also once again advised on refraining from alcohol or
further cocaine use and the risk of sudden cardiac death. |
