Transcript Journal Club

Clinical Correlations
The NYU Langone Online Journal of Medicine
http://clinicalcorrelations.org
NYU Medicine Grand Rounds
Clinical Vignette
December 4, 2013
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 41
year old woman BIBEMS for
one hour of crushing substernal
chest pressure
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient is an active smoker who has not seen
a primary care physician for many years other than
during pregnancy.
•In the weeks prior to presentation, she noted mild
shortness of breath and fatigue with exertion, but
no prior chest pain.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•None
•Past Surgical History:
•Cholecystectomy
•Tubal ligation
•Social History:
•Smokes 1 pack per day for over twenty years,
denies alcohol or illicit drug use
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Family History:
•Mother- hypertension, diabetes
•Father- hypertension
•No known history of early coronary artery
disease or sudden death
•Allergies:
•No Known Drug Allergies
•Medications:
•No medications
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: Overweight Hispanic woman lying in
stretcher in moderate distress
•Vital Signs: T: 97.7 F, BP: 141/90, HR: 89, RR: 18,
and O2 sat: 100% on room air
•Remainder of Physical Exam was normal other
than prominent abdominal obesity
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: WBC 13.8 (53% neutrophils)
•Remainder of CBC was within normal limits
•Basic Metabolic panel: within normal limits
•Hepatic panel: within normal limits
•Troponin: 0.219, 3.6, >50
•Lipid Panel: Total Cholesterol 133, HDL 23,
LDL 46, Triglycerides 322
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
EKG
ST elevation in v1-v6, I, aVL, ST depressions in III
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The patient was taken for urgent cardiac
catheterization and had a drug eluting stent
placed to the mid-LAD with an ejection
fraction of 25%
• On hospital day 3, she was discharged on
aspirin 81mg, clopidogrel 75mg, atorvastatin
80mg, metoprolol 12.5mg and lisinopril 2.5mg
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Post-discharge Follow-up
• In the months following discharge, the patient
quit smoking with the use of buproprion and
nicotine replacement therapy
•She became more physically active, but was
not able to significantly change her diet or lose
weight.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Post-discharge Follow-up
Repeat labs one month after discharge on
atorvastatin 80 mg
•Fasting lipids- total cholesterol- 138, HDL
29, LDL- 30, triglycerides 397
•HbA1C- 6.6
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Post-discharge Follow-up
•Based on this data, atorvastatin was
decreased to 40 mg daily, fenofibrate 160 mg
daily and metformin 500 mg BID were added.
•Lipid panel after several months of this
therapy:
• Total cholesterol- 143, HDL 30, LDL 82,
triglycerides 155
• HbA1C- 5.9
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Follow-up Questions
•Is the patient optimally treated on current
therapy based on old and new prevention
guidelines?
•Should any medical therapies be added?
•Should any medical therapies be removed?
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS