May 2004         

HISTORY:
The patient is a 60-year-old white woman who presented from a small rural hospital after presenting there with acute onset of right hip pain after a fall at home. The patient states that she tripped and fell on a carpeted concrete floor, landing on her right side.  Soon after, she noticed severe right hip pain. She was not able to get up by herself initially so she notified an ambulance; however, was reluctant to get into the ambulance and rode her scooter to the nearby hospital with the ambulance following and she was transferred to UAMS for further work-up of her hip pain. In the ER at UAMS, labs revealed a troponin of 2.3.

PAST MEDICAL HISTORY:
Hypertension, coronary artery disease, status post CABG times two vessels with a redo CABG times three vessels in 1989. Type II diabetes.

FAMILY HISTORY:
Father with cancer. Mother with coronary disease and diabetes.
Sister with hypertension.

SOCIAL HISTORY:
Patient lives alone.

HABITS:
Tobacco: One pack per day times 52 years. No alcohol or drugs.

MEDICATIONS:
Glucophage 500 mg p.o. q.d., Ambien 10 mg p.o., potassium chloride 10 mg p.o. q.d., Lasix 40 mg p.o. q.d., Actonel 5 mg p.o. q.d., home O2.

PHYSICAL EXAMINATION:
Physical exam on admission: Heart rate 90, blood pressure 121/72, pulse oximetry 90% on two liters. General: Middle-aged, awake, alert and oriented, white woman, appears anxious, labile mood. HEENT:
Pupils are equal, round, and reactive to light. Extraocular muscles intact. Sclera are clear. Chest clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. Normal S1 and S2. Abdomen: Soft, nontender, nondistended, normal bowel sounds. No organomegaly.  Extremities: No clubbing, cyanosis or edema. Left below-knee amputation.

LABORATORY DATA:
Electrolytes: CBC and coagulation studies within normal limits. CK:183, CK MB 5.8, troponin 2.3. Cholesterol panel within normal limits.  EKG demonstrated sinus rhythm with frequent PVCs. Rate of 94, no ST changes, inferolateral T wave changes. Poor R wave progression.  Chest x-ray demonstrated post sternotomy changes, cardiomegaly, CT of the right hip demonstrated severe osteoarthritis with severe joint space narrowing and subchondral cysts and sclerosis involving both the acetabulum and femoral head. No acute fracture.
 

HOSPITAL COURSE:
The patient was admitted to the CCU and monitored on telemetry.  Serial cardiac enzymes were followed. She was started on beta blocker, aspirin, and heparin. Orthopedic surgery was consulted for evaluation of right hip. Troponin peaked at 4 and decreased the next day to 2.7. She underwent Persantine Sestamibi stress test on 01/29/2004, demonstrating reversible defect of the anteroseptal wall with a large fixed defect of the inferior wall with only minimal peri-infarct ischemia with ejection fraction of 41%. The results were
discussed with patient who stated that she did not want cardiac catheterization to be done. She was evaluated by orthopedic surgery who recommended white blood cell scan to evaluate the possibility of
right hip fracture not seen on CT scan; however, patient also refused this procedure. The risks and benefits of cardiac catheterization as well as white blood cell scan to evaluate for fracture were discussed
with patient who remained firm in her resistance to either procedure.  She was therefore continued on medical management and deemed stable for discharge home.

  Click here to see magnified images.

Nuclear Medicine Report:

A 60 year-old patient with a history of coronary disease and two previous bypass operations in 1980 for coronary disease who presents with syncope and elevated Troponin levels. The study is requested for evaluation of myocardial ischemia.

IV Persantine stress. Under rest conditions, the patient was injected with a maximum of 60 mg of IV Persantine over 4 minutes. The resting heart rate was 90 beats per minute and blood pressure 130/66. The EKG demonstrated normal sinus rhythm with old inferior myocardial infarction and old anteroseptal myocardial infarction. No acute changes were identified. Following Persantine infusion, the heart rate measured 94 beats per minute and blood pressure 145/78. The patient experienced severe nausea with Persantine infusion but no chest pain. EKG demonstrated no change and the symptoms of nausea resolved upon the completion of the test and the IV administration of 100 mg of aminophylline.

IMPRESSION: MODERATE HEART RATE RESPONSE TO PERSANTINE PERFUSION BUT NO ISCHEMIC CHANGE IDENTIFIED.

Myocardial perfusion with SPECT. Under rest conditions, the patient was injected with 11 mCi Tc-99m labeled sestamibi. SPECT images of the myocardium were obtained at an hour delay. Seven minutes into the Persantine infusion, the patient was injected with 35 mCi Tc-99m labeled sestamibi. The imaging sequence was repeated at an hour delay.

The post stress images demonstrate a large defect in perfusion involving the anteroseptal wall of the left ventricle. The mid septum is perfused. There is a large defect involving the inferior septal wall extending to involve the entire inferior wall of the left ventricle into the inferolateral wall. On the rest images, the anteroseptal wall filled in and is contiguous with the remaining septum. The large inferior septal and inferior wall defect is still present. There has been a minimal reperfusion identified along the lateral aspect of this inferior wall defect.

IMPRESSION:
1. REVERSIBLE DEFECT OF THE ANTEROSEPTAL WALL WITH A LARGE FIXED DEFECT OF THE INFERIOR WALL WITH ONLY MINIMAL PERI-INFARCT ISCHEMIA SEEN LATERALLY.
2. THE EXACT ANATOMIC DISTRIBUTION WOULD BE DIFFICULT IN A PATIENT STATUS POST TWO PREVIOUS CABG OPERATIONS. IT WOULD BE CONSISTENT WITH A DISTRIBUTION IN THE LAD SYSTEM.

Quantitative gated SPECT. Gated SPECT study was performed during stress acquisition. The end diastolic volume calculated at 176 cc, the end systolic volume at 103 cc, and the left ventricular ejection fraction at 41 percent. Review of CINE demonstrated a dilated appearing left ventricle. Global hypokinesis is noted with akinesis noted of the inferior wall of the left ventricle.

IMPRESSION: DILATED LEFT VENTRICLE WITH GLOBAL HYPOKINESIS. SEVERE COMPROMISE OF THE LEFT VENTRICULAR FUNCTION WITH AN EJECTION FRACTION OF 41 PERCENT.

PRINCIPAL DIAGNOSIS:
Coronary artery disease with chest pain.

SECONDARY DIAGNOSIS:
Severe osteoarthritis of the right hip.

PROCEDURE(S):
CT scan of the right hip. Persantine Sestamibi stress test.

CONSULTATION(S)
Orthopedic surgery.

DISCHARGE DIET:
Low sodium, low cholesterol, activity as tolerated.

DISCHARGE MEDICATIONS:
Patient to continue home medications with the addition of gabapentin 100 mg p.o. t.i.d., Protonix 40 mg p.o. q.d.

FOLLOWUP:
Patient will be followed in the medical clinic with doctor in one month for re-evaluation of chest pain as well as right hip pain.

© 2004 Nuclear Education Online

Images courtesy of UAMS Dept of Nuclear Medicine.