Transcript MGR Case Report - Clinical Correlations

Clinical Correlations
The NYU Internal Medicine Blog
A Daily Dose of Medicine
http://clinicalcorrelations.org
Medical Grand Rounds
Clinical Vignette
December 17th, 2008
Anjali Grover, M.D.
Chief Complaint
A 45 year old Hispanic male presents with
chest pain for 45 minutes.
History of Present Illness
The patient was well until the evening of
admission when he had the sudden onset
of non-radiating, sub-sternal chest
pressure while walking.
The chest pain was associated with
shortness of breath, light-headedness,
palpitations, diaphoresis and nausea
without vomiting.
Additional History
Past Medical History:
– Hyperlipidemia
– Depression
Past Surgical History: none
Social history:
–
–
–
–
Current smoker with a 25 pack year history
Denies ethanol or illicit drug use
Family History:
Mother died of a myocardial infarction at age 76
Allergies:
No known drug allergies
Medications:
-- Simvastatin 40 mg daily
-- Aspirin 81 mg daily
-- Fluoxetine 20 mg daily
Physical Exam
General: In mild distress appearing anxious
secondary to chest pain, appeared his stated age.
T:97.1oF BP:159/82 HR:84 RR:16 O2:97%RA
The remainder of the physical exam was normal
Laboratory
Troponin
Time 0 hours
Time 8 hours
0.09 (normal <0.07)
0.01
Basic Metabolic Panel normal
Complete Blood Count normal
Hepatic Function Panel normal
Imaging
ECG: Sinus rhythm with rate of 63, 2 mm ST elevation
in V2, 1 mm up-slanting ST depression in II, III, aVf.
Chest X-Ray: No evidence of pulmonary congestion,
infiltrate or effusions.
Working Diagnoses
Acute Coronary Syndome: ST Elevation
Myocardial Infarction (STEMI)
Brugada Syndrome
Hospital Course
Emergency Room course:
–
Treated with:
Aspirin 325mg
Clopidogrel 300mg
Lopressor 5 mg IVP x 3
Morphine 4mg IVP
Sub-lingual Nitroglycerine 0.4mg x 3
Heparin drip
Lipitor 80 mg
The patient remained hemodynamically
stable, EKG changes were stable and his
chest pain resolved.
Hospital Course
Hospital Day #1:
 Cardiac Catheterization revealed clean coronary
arteries
 Transthoracic Echocardiogram showed no
abnormalities
Hospital Day #2:
 Procainamide challenge performed to evaluate for
possible manifestations of Brugada Syndrome on
EKG.
 With procainamide, the patient’s 2mm “saddle-back”
ST segment elevation in V2 converted to a “coved”
ST segment elevation pattern.
 These findings represented a positive procainamide
challenge.
Hospital Course
Hospital Day #3:
 Electrophysiology Study performed for further risk stratification
revealed no inducible ventricular arrhythmias.
Intracardiac defibrillator placement was recommended to
the patient, but he refused.
He was discharged on Aspirin and Zocor.
6 months later on follow-up in Cardiology Clinic, the
patient agreed to ICD placement. It was placed shortly
thereafter.
Final Diagnosis
Type 2 Brugada Syndrome