New Concepts in Acute Coronary Syndromes Beyond 2000 (XX) Interactive Case Presentations

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Candice Hicks
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1 New Concepts in Acute Coronary Syndromes Beyond 2000 (XX) Interactive Case Presentations Dr. Richard Bon Surrey Memorial Hospital, Surrey, BC Canadian Cardiovascular Congress 2014 October 26, 2014

2 Conflicts of Interest/Disclosures None

moderate CAD of OM2 Echo in India: LVEF~45%, lateral hypokinesis Meds at d/c: ASA 81 mg OD, clopidogrel 75 mg OD, irbesartan 150 mg OD,

3 Case 1: Presenting History 65 M, South Asian, DM, HTN, +LDL, obese, hypothyroid July 12: NSTEMI while visiting India; chest heaviness, +troponins, lateral T wave inversions Cath in India: PCI of ostial left Cx and OM1 with DES x 2 Mild CAD of dominant RCA & LAD, moderate CAD of OM2 Echo in India: LVEF~45%, lateral hypokinesis Meds at d/c: ASA 81 mg OD, clopidogrel 75 mg OD, irbesartan 150 mg OD, levothyroxin 125 mcg OD, glyburide 10 mg bid, metformin 1 g bid Uneventful recovery, flew back to Canada July 19 Mobilizing and improving at home

4 Case 1: Presenting History July 22 (10 days post PCI): awoke at 08:30 with epigastric and left shoulder pain (dissimilar to prior NSTEMI) lasting 20 min 10:00 recurrent lower RSCP/epigastric pain, vomiting x 4; no hematemesis or melena; EHS called Presented to SMH ER at 10:50: BP 85/49, HR 60, 98% R/A; 3L IV NS given for hypotension; no NTG given. Pain relieved with 5 mg IV morphine. Labs: WBC 12.5, Hgb 112 (123 at d/c), plts 250, Na 131, K 5.1, Cr 98, GFR 48. Trop I 0.39 (N<0.04; decreased from 17 in India) Presenting ECG at 11:00

Case 1: Presenting History Managed in ER for presumed gastroenteritis; seen by Hospitalist service No further CP or shoulder pain post morphine + epigastric pain, vomiting X 1 BP improved with IV

6 Case 1: Presenting History Managed in ER for presumed gastroenteritis; seen by Hospitalist service No further CP or shoulder pain post morphine + epigastric pain, vomiting X 1 BP improved with IV saline at 100 cc/hr; 114/56 mm Hg, HR bpm Remained drowsy, felt to be secondary to morphine 6 hr troponin I (16:00) = 0.42 ng/ml (increased from 0.39) Repeat ECG at 6 hrs (16:00) unchanged from admission

7 Case 1: Hospital Course Intermittent episodes of RSCP and epigastric pain partially relieved with NTG, but morphine also given Vitals similar to previous July 22, 10hr labs (21:00) WBC 13, Hgb 100, plts 247, INR 1.2, electrolytes normal Cr 121, GFR 38 Trop I 74.7 Cardiology now consulted, ECG (standard and posterior leads) ordered

9 R / V8 / V9

10 Case 1: Hospital Course Cardiology assessment No chest, shoulder, epigastric pain; ++ dyspnea (requiring BiPAP) 114/53 mm Hg, 71 bpm, 94% O2 sats on 35% FiO2 BiPAP Bilateral crackles to mid lung zones JVP ~ 6 cm ASA, NL heart sounds, 2/6 HSM at apex/llsb Abdomen soft, no epigastric tenderness IV saline stopped, 80 mg IV furosemide given ASA 81 mg, clopidogrel 75 mg, 5000 U IV UFH added Cath lab contacted: suspected stent thrombosis Total ischemic time unclear

11 Case 1: Hospital Course Local cath lab (9 min transport time) 21:30 (10.5 hrs post presentation) Given ostial location of Cx stent, felt need for surgical backup Surgical backup unavailable Contacted second cath 21:40 (45-60 min transport time) Reperfusion choice?

12 Case 1: Hospital Course Decision made to intubate and transfer Complicated by refractory hypotension requiring vasopressors Echo performed while awaiting ambulance LVEF~30-35%; inferior, inferolateral, and lateral HK; moderate MR Cath lab arrival at 23:00 (12hr post presentation) Transfer time of 45 min 97/46 mm Hg (20 mcg/min norepinephrine); IABP inserted

14 Case 1: Post PCI Course Admitted to CCU of PCI-hospital Integrelin bolus + infusion (18 hrs) started in cath lab Ticagrelor 180 mg given in CCU IABP and pressors/inotropes weaned off within 48 hrs Echo July 29 EF~35%, inferior, inferolateral, lateral HK Transferred back to referring hospital and discharged to Heart Function Clinic after period of convalescence

15 CASE 2

16 Case 2: Presenting History 54 M, South Asian long-haul truck driver, HTN, DM2, dyslipidemia 3 months - episodic epigastric pressure with heavy meals Denies exertional CP, SOB, palpitations; sedentary 6 weeks prior - EST: 7.7 mets, nondiagnostic - minor baseline inferior T wave abnormalities. No chest pain. MPI recommended 1 week prior - Ex-MPI: extensive ischemia of the distal inferior, distal anteroseptal, and apical segments. Preserved LVEF. Presents with 2 hrs epigastric/low RSCP. Darker stools.

17 Case 2: Presenting History PMHx: GERD, mildly active rheumatoid arthritis, sciatica, obesity Meds: ASA 81 mg prn bisoprolol 5 mg OD rosuvastatin 10 mg OD metformin 500 mg bid hydroxychloroquine 200 mg OD naproxen 500 mg bid Compliance questionable according to family

18 Case 2: Presenting History Exam: 152/86 mm Hg; NSR 84 bpm, O 2 sats 98% R/A Normal cardio-pulmonary exam Abdomen soft, epigastric tenderness; OB+ WBC 11.4, Hgb 68 (MCV 92), Plts 241 Normal electrolytes, renal function, & coags Troponin I ng/ml (Normal <0.04 ng/ml)

19 Case 2: Presenting ECG

20 What would be your initial management?

21 Case 2: Hospital Course Transfused 4 U PRBC over 6 hours Furosemide 40 mg IV given after 2 U and 4 U Hgb 102 post transfusion; well tolerated GI consult pantoprazole infusion started; naproxen held UGI endoscopy: bleeding gastric ulcer, injected and cauterized

22 Case 2: Hospital Course Second troponin I ( 12 post presentation) increased from 2.6 ng/ml to 12.1 ng/ml; CCU consulted Persistent epigastric discomfort and low RSCP BP 138/74 mm Hg, HR 87 bpm; exam unchanged ASA held (as per GI), clopidogrel 300 mg load + 75 mg OD, UFH infusion (no bolus), bisoprolol 10 mg OD, perindopril 4 mg OD, rosuvastatin 40 mg OD IV NTG 20 mcg/min initiated for CP symptoms Echo: LVEF~50%, inferior and inferolateral hypokinesis Referred for urgent cath

23 90

24 Case 2: Hospital Course (Nov 20) Cath: RCA felt to be culprit vessel PCI of prca and drca with BMS x 2; clopidogrel x 1 month minimum CVT consulted for revascularization of LAD and Cx CVT suggested deferral of CABG until medically stable from GI bleed and NSTEMI; as outpatient in 8 weeks, if no angina Pt returned to SMH, weaned off NTG, and remained asymptomatic on clopidogrel & medical therapy

25 Case 2: Post PCI ECG

26 Case 2: Follow Up At 4 wk clinic follow up, patient reported recurrent symptoms CABG performed (LIMA to LAD, SVG to OM1, SVG to OM2) Currently stable 6 months post CABG and cardiac rehab; has returned to commercial driving

27 Thank you

Difficult Data Definitions and Scenario s

Difficult Data Definitions and Scenario s Presenter Disclosure Information Cornelia Anderson BSN, RN To following relationships exist related to this presentation: No Disclosures Objectives Discuss key