Case Based Decision Making: A Critical Review of Interventions

Eckhard Alt, M.D.

Robert Smith, M.D.

Cardiac Catheterization Conference

March 30, 2004

Case Presentation

LC is a 94 yo white male with PMHx significant for HTN, DM who presented on 2/18/04 with c/o severe retrosternal chest pain. He reported that the chest pain began approximately 4 hours prior to presentation to the ER and awakened him from sleep. The chest pain was initially mild but gradually increased in severity over time, prompting him to call EMS for transport to the emergency room. He described the chest pain as “crushing” and with radiation to the left arm. He reported associated SOB, diaphoresis, and nausea.

Past Medical History

• HTN

• DM

• CRI (1.4 – 1.6)

• Remote h/o colon cancer s/p resection

• BPH

Medications

• ASA 81mg

• Protonix 40mg

• Diltiazem 120mg

• Lisinopril 5mg

• 70/30 insulin

Physical Exam

• 154/56 81 18 36.0

• NAD

• No JVD

• Normal S1S2, no murmurs

• Few basilar crackles

• Benign Abdomen

• No edema

Labs

• Na 133• K 4.6• Cl 101• CO2 24• BUN 23• Cr 1.8• TP 5.9• ALB 2.9• AST 28• ALT 30• Troponin 0.13

• WBC 7.8• HGB 12.4• HCT 38.2• PLT 249

Case PresentationKD is a 62 yo male with PMHx significant for HTN and hyperlipidemia who presented to his primary care physician in February of 2004 with c/o chest discomfort. He described the chest discomfort as retrosternal, pressure like, and without radiation or other associated symptoms. He reported that the discomfort had been occurring approximately once every 2 weeks for the last 3 months and that it was not related to exertion. Subsequently, he had an adenosine cardiolyte stress test which showed an inferolateral reversible defect. Because of this, he was referred for elective LHC.

Past Medical History

• HTN

• Hyperlipidemia

Medications

• ASA 81mg

• Lopressor 25mg BID

• HCTZ 25mg

• Lisinopril 10mg

• Simvastatin 40mg

Physical Exam

• 142/80 70 12 36.8

• NAD

• No JVD

• Normal S1S2, no murmurs

• Chest clear

• Abdomen benign

• No edema

Labs

• Na 138

• K 3.9

• Cl 105

• CO2 28

• BUN 18

• Cr 0.8

• Glu 96

• Mg 2.4

• Troponin <0.01

• WBC 4.9• HGB 11.3• HCT 34.0• PLT 299

Case Presentation

WL is a 72 yo male with PMHx significant for CAD s/p CABG several years previously who presented to his primary care physician with c/o chest pain. Pt. Reported that the chest pain had begun 4-5 months prior to presentation and had been increasing in frequency since onset. He reported that the chest pain was squeezing in nature and with radiation to his left arm. He reported that it was unrelated to exertion and was not relieved with SL NTG. He reportedly had some type of stress test which was positive (details not available) and was referred to the VAMC for elective LHC.

Past Medical History

• CAD s/p 2V CABG in the early 1990’s

• HTN

• Hyperlipidemia

• S/P right CEA

Medications

• Diltiazem 120mg

• Simvastatin 40mg

Physical Exam

• 170/84 70 18 36.2

• NAD

• No JVD

• Normal S1S2, 2/6 SEM LUSB

• Chest clear

• Abdomen Benign

• No edema

Labs• Na 142• K 3.9• Cl 111• CO2 25• BUN 15• Cr 1.2• Glu 107• Alb 4.0• TP 7.9• AST 13• ALT 38• Troponin <0.03

• WBC 6.4• HGB 13.2• HCT 40.2• PLT 247

Case Presentation

RT is a 57 yo male with PMHx significant for HTN, Hyperlipidemia, tobacco abuse who presented in February of 2004 with c/o chest pain. He reported that the chest pain had begun 5 days prior to presentation and had been progressive in frequency and severity since onset. He described the chest pain as “burning” in nature with associated “tingling” in his left arm. He reported that it occurred with exertion and at rest and was often associated with nausea. He had tried antacids without relief of his symptoms. On the day of his presentation, he experienced approximately 2 hours of chest pain prior to coming to the ER. In the ER, the chest pain was relieved with SL NTG.

Past Medical History

• HTN

• Hyperlipidemia

• Lower Back Pain

Medications

• Atorvastatin 40mg

• ASA 325mg

• Atenolol 50mg

Physical Exam

• 112/62 67 14 36.8

• NAD

• No JVD, no bruits

• Normal S1S2, no murmurs

• Chest clear

• Abdomen benign

• No edema

Labs

• Na 140• K 5.1• Cl 104• CO2 30• Glu 156• BUN 16• Cr 0.9• Alb 4.4• TP 7.7• AST 26• ALT 33

• Troponin 0.23

• WBC 7.1• HGB 16.4• HCT 48.7• PLT 219

Case Presentation

JL is a 54 yo AAM with PMHx significant for DM, HTN who presented to his primary care doctor in January, 2004 with c/o chest discomfort. He described the discomfort as pressure like and with radiation to his left arm. He reported associated SOB. He reported that the discomfort did not occur at rest but was reliably reproduced with walking approximately 1 block. He was referred for exercise stress test, during which he developed severe retrosternal chest pain with 3mm ST segment depressions inferiorly and 2mm ST segment elevations in V1-V3. ECG returned to baseline with rest and SL NTG. Pt was sent upstairs for LHC.

Past Medical History

• Poorly controlled DM

• HTN

Medications

• HCTZ 50mg

• 70/30 insulin

• Metformin 1000mg BID

• Ramipril 10mg

Physical Exam

• 156/82 88 20 37.0

• NAD

• No JVD, n o bruits

• Normal S1S2, no murmurs

• Chest clear

• Abdomen benign

• No edema

Labs

• Na 137• K 4.0• Cl 101• CO2 27• Glu 146• BUN 13• Cr 0.9

• WBC 16.8• HGB 15.5• HCT 46.2• PLT 293