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ACP FLORIDA CHAPTER CLINICAL VIGNETTE ORAL PRESENTATION
Vertilio M. Cornielle, M.D. PGY-3
March 2nd, 2013
Mount Sinai Medical Center, Miami Beach
CORONARY MILKING: A RARE CAUSE OF CHEST PAIN AND ELEVATEDOF CHEST PAIN AND ELEVATED
CARDIAC ENZYMES
Clinical
CHIEF COMPLAINT: CHEST PAINVignette
HistoryHistory
• A 56 year-old woman from Mexico comes to the emergency
HistoryHistory
PhysicalPhysical
Laboratory Laboratory y g ydepartment complaining of anterior chest pain for approximately two hours.
yy
ImagingImaging
Hospital Hospital
• The pain was described as oppressive, 10/10 in intensity,radiating to her left arm and back, and associated with shortness of breath and palpitations.
CourseCourse
Left Heart Left Heart CatheterizationCatheterizationp p
• The pain gets worse lying down and improves by leaning forward.
DiagnosisDiagnosis
DiscussionDiscussion
Clinical Vignette
HistoryHistory
• Sh d i DOE PND l iti h t i
HistoryHistory
PhysicalPhysical
Laboratory Laboratory • She denies DOE, PND or pleuritic chest pain.
• She had similar pain one month previously while in Mexico.
yy
ImagingImaging
Hospital Hospital
• A complete cardiac evaluation was performed, includingECG, echocardiogram and an exercise stress test, that
CourseCourse
Left Heart Left Heart CatheterizationCatheterization
showed no findings suggestive of ischemia.DiagnosisDiagnosis
DiscussionDiscussion
Clinical Vignette
HistoryHistory
• PAST MEDICAL HISTORY
1 Hypothyroidism
PhysicalPhysical
Laboratory Laboratory 1. Hypothyroidism
2. Hiatal Hernia
ImagingImaging
Hospital Hospital CourseCourse
• PAST SURGICAL HISTORY Left Heart Left Heart Cardiac Cardiac
CatheterizationCatheterization1. C-section x 3
2. Breast Implants
CatheterizationCatheterization
DiagnosisDiagnosis
DiscussionDiscussionscuss oscuss o
Clinical Vignette
HistoryHistory
• MEDICATIONS
1 L th i 25 d
PhysicalPhysical
Laboratory Laboratory
1. Levothyroxine 25 mg qd ImagingImaging
Hospital Hospital CourseCourse
• ALLERGIESLeft Heart Left Heart
Cardiac Cardiac CatheterizationCatheterization
1. SulfasCatheterizationCatheterization
DiagnosisDiagnosis
DiscussionDiscussionDiscussionDiscussion
Clinical Vignette
HistoryHistory
FAMILY HISTORY
1 M th CAD d CABG 3
PhysicalPhysical
Laboratory Laboratory
1. Mother: CAD and CABG x 3 ImagingImaging
Hospital Hospital CourseCourse
• CHILDHOOD DISEASESLeft Heart Left Heart
Cardiac Cardiac CatheterizationCatheterization
1. NoneCatheterizationCatheterization
DiagnosisDiagnosis
DiscussionDiscussionscuss oscuss o
Clinical Vignette
HistoryHistoryINFECTIOUS DISEASES
1. None
HistoryHistory
PhysicalPhysical
Laboratory Laboratory
• SOCIAL AND MARITAL HISTORY
yy
ImagingImaging
Hospital Hospital
1. Lives in Mexico with husband and her 3 daughters.
2. Housewife, currently on vacation with her family.
CourseCourse
Left Heart Left Heart CatheterizationCatheterization
3. Previous smoker, 1 PPD for approx. 30 yrs. Quit 8 yrs ago.
4 Drinks an occasional glass of wine no drugs
DiagnosisDiagnosis
DiscussionDiscussion4. Drinks an occasional glass of wine, no drugs.
Clinical Vignette
HistoryHistory
REVIEW OF SYSTEMS
E d i + h t ld i t l l i
PhysicalPhysical
Laboratory Laboratory
Endocrine: + heat or cold intolerance no polyuria orpolydipsia.
ImagingImaging
Hospital Hospital CourseCourse
Cardiovascular: + chest pain and palpitations, no DOE, PND
Respiratory: No cough pleuritic chest pain or + SOB
Left Heart Left Heart Cardiac Cardiac
CatheterizationCatheterizationRespiratory: No cough, pleuritic chest pain or + SOB.
Rest of the review of system is unremarkable.
CatheterizationCatheterization
DiagnosisDiagnosis
DiscussionDiscussionscuss oscuss o
Clinical Vignette
HistoryHistory
Physical Exam:
Vitals: Temp: 98 3 BP: 102/58 HR: 74 (SR) RR: 18
PhysicalPhysical
Laboratory Laboratory Vitals: Temp: 98.3 BP: 102/58 HR: 74 (SR) RR: 18
General Appearance: good appearance, well hydrated.
ImagingImaging
Hospital Hospital CourseCourse
HEENT: PERRL, NL EOM. Left Heart Left Heart Cardiac Cardiac
CatheterizationCatheterizationSkin: No lesions or rashes.
Neck: No JVD, no carotid bruits no masses.
CatheterizationCatheterization
DiagnosisDiagnosis
DiscussionDiscussionDiscussionDiscussion
Clinical Vignette
HistoryHistory
Thorax: Normo-dynamic, no deformities. PhysicalPhysical
Laboratory Laboratory
Breast: No masses, no skin changes and no drainage.ImagingImaging
Hospital Hospital CourseCourse
Lungs: CTA Bl, no abnl BS. Left Heart Left Heart Cardiac Cardiac
CatheterizationCatheterization
Cardiac: regular rhythm, nl s1 and s2, no murmurs,rubs or gallops.
CatheterizationCatheterization
DiagnosisDiagnosis
DiscussionDiscussionDiscussionDiscussion
Clinical Vignette
HistoryHistory
Abdomen: Soft, NT, ND + BS, no masses. PhysicalPhysical
Laboratory Laboratory
Genitourinary: No CVA tenderness.ImagingImaging
Hospital Hospital CourseCourse
Extremities: nl pulses, no edema.Left Heart Left Heart
Cardiac Cardiac CatheterizationCatheterization
Lymph Nodes: No lymphadenopathy.
CatheterizationCatheterization
DiagnosisDiagnosis
DiscussionDiscussionDiscussionDiscussion
Clinical Vignette
HistoryHistory
Musculoskeletal: No deformities, joint tenderness, swellingff i
PhysicalPhysical
Laboratory Laboratory
or effusions. ImagingImaging
Hospital Hospital CourseCourse
Neurological: CN II-XII intact, with no motor deficits or sensory deficits Gait wnl and DTR unable to evaluate at
Left Heart Left Heart Cardiac Cardiac
CatheterizationCatheterizationsensory deficits. Gait wnl and DTR unable to evaluate at the time.
CatheterizationCatheterization
DiagnosisDiagnosis
DiscussionDiscussionscuss oscuss o
Clinical DIAGNOSTIC STUDIES
PERFORMED IN THE ERVignette
HistoryHistory
141 107 1212 0
PhysicalPhysical
Laboratory Laboratory 141
4.1
107
27
12
0.44 1067.2812.0
36.7157 ImagingImaging
Hospital Hospital CourseCourse
TSH 0.005
Cholest 99 trig 46 HDL 32
CKMB 1st 0.5
CPK 63
CourseCourse
Left Heart Left Heart Cardiac Cardiac
C th t i tiC th t i tiCholest 99, LDL 58
trig 46, HDL 32Trop 0.092
CatheterizationCatheterization
DiagnosisDiagnosis
DiscussionDiscussionDiscussionDiscussion
Clinical DIAGNOSTIC STUDIES
PERFORMED IN THE ERVignette
HistoryHistoryHistoryHistory
PhysicalPhysical
LaboratoryLaboratoryLaboratory Laboratory
ImagingImaging
Hospital Hospital ppCourseCourse
AngiographyAngiography
DiagnosisDiagnosis
DiscussionDiscussion
Clinical
DIFFERENTIAL DIAGNOSISVignette
CHEST WALL PAIN
1. Musculoskeletal pain
2. Isolated musculoskeletal chest pain syndromes
3. Rheumatic diseases
GASTROINTESTINAL CAUSES OF CHEST PAIN
1. Gastroesophageal reflux disease
2. Esophageal hyperalgesia
3. Abnormal motility patterns and achalasia
4. Nonrheumatic systemic diseases
5. Skin and sensory nerves
CARDIAC CAUSES OF CHEST PAIN
4. Esophageal rupture, mediastinitis, and foreign bodies
5. Medication-induced esophagitis
6. Other gastrointestinal causes of chest pain
1. Coronary heart disease
2. Aortic dissection
3. Valvular heart disease
PULMONARY CAUSES OF CHEST PAIN
1. Pulmonary vasculature
2. Acute pulmonary thromboembolism
3. Pulmonary hypertension and cor pulmonale
4 Lung parenchyma4. Pericarditis
5. Myocarditis
6. Stress-induced cardiomyopathy
7. Cardiac syndrome X
4. Lung parenchyma
5. Pneumonia
6. Cancer
7. Sarcoidosis
8. Pleura and pleural space8. Pheochromocytoma
PSYCHOGENIC/PSYCHOSOMATIC CAUSES OF CHEST PAIN
9. Pneumothorax
10. Pleuritis/serositis
11. Pleural effusion
12. Mediastinal disease
Clinical
HOSPITAL COURSEVignette
HistoryHistory
• In the emergency department the patient had an ECGperformed that showed normal sinus rhythm and possible left atrial enlargement but no ST segment or T wave abnormalities suggesting
PhysicalPhysical
Laboratory Laboratory
ischemia.
• CTA performed showed no signs of PE, Ao dissection or
Hospital CourseHospital Course
ImagingImaging
L f HL f HPNA.
• Patient was then admitted to the telemetry floor and was t t d NSTEMI
Left Heart Left Heart Cardiac Cardiac
CatheterizationCatheterizationtreated as a NSTEMI.
• Echocardiogram, repeat ECG’s and subsequent two sets oftroponins trended down to normal
DiagnosisDiagnosis
DiscussionDiscussiontroponins trended down to normal.
Clinical
HOSPITAL COURSEVignette
HistorHistor• However on day 2 of hospitalization the patient again
complained of severe precordial chest pain, this time d i h h d i i i f i l i
HistoryHistory
PhysicalPhysical
LaboratoryLaboratoryworsened with the administration of nitroglycerin. Laboratory Laboratory
Hospital CourseHospital Course
ImagingImaging• Repeat Troponin and CK MB were elevated at 0.611
and 4.7 respectively, without any changes on ECG’s.
g gg g
Left Heart Left Heart CatheterizationCatheterization
• Left heart catheterization was performed that showed:
DiagnosisDiagnosis
DiscussionDiscussion
Clinical LEFT HEART CARDIAC
CATHETERIZATIONVignette
HistorHistorHistoryHistory
PhysicalPhysical
LaboratoryLaboratoryLaboratory Laboratory
Hospital Hospital CourseCourse
Left Heart Left Heart CatheterizationCatheterization
DiagnosisDiagnosisDiagnosisDiagnosis
DiscussionDiscussion
Clinical LEFT HEART CARDIAC
CATHETERIZATIONVignette
HistorHistorHistoryHistory
PhysicalPhysical
LaboratoryLaboratoryLaboratory Laboratory
Hospital Hospital CourseCourse
Left Heart Left Heart CatheterizationCatheterization
DiagnosisDiagnosisDiagnosisDiagnosis
DiscussionDiscussion
Clinical
HOSPITAL COURSEVignette
HistorHistor
• Left Heart Catheterization results: myocardial b id i f h i l l f i d di
HistoryHistory
PhysicalPhysical
LaboratoryLaboratorybridging of the proximal left anterior descending coronary artery with no evidence of obstructive disease.
Laboratory Laboratory
Hospital Hospital CourseCourse
• No intervention was performed and the patient was
Left Heart Left Heart CatheterizationCatheterization
DiagnosisDiagnosis• No intervention was performed and the patient was discharged home and managed medically with aspirin and calcium channel blockers.
DiagnosisDiagnosis
DiscussionDiscussion
Clinical
CORONARY BRIDGING Vignette
HistorHistorHistoryHistory
PhysicalPhysical
LaboratoryLaboratoryLaboratory Laboratory
Hospital Hospital CourseCourse
Left Heart Left Heart CatheterizationCatheterization
DiagnosisDiagnosisDiagnosisDiagnosis
DiscussionDiscussion
Clinical
MYOCARDIAL BRIDGINGVignette
HistorHistor• Coronary arteries occasionally have a segmental
intra-myocardial course.
D i l hi f h l i d
HistoryHistory
PhysicalPhysical
LaboratoryLaboratory• During systole, this segment of the vessel is compressed, a condition referred to as milking or systolic "myocardialbridging".
Laboratory Laboratory
Hospital Hospital CourseCourse
• This phenomenon was first recognized more than 200 years ago by Reyman, HC. Disertatis de vasis cordis propiis. Bibl Anat.1737;2:366.
Left Heart Left Heart CatheterizationCatheterization
DiagnosisDiagnosis
• First reported in depth in 1951.
• First recognized angiographically in 1960
DiagnosisDiagnosis
DiscussionDiscussion
First recognized angiographically in 1960.
Clinical
MYOCARDIAL BRIDGINGVignette
HistorHistor• Severe bridging of the major coronary arteries can produce
myocardial ischemia, coronary thrombosis, myocardial infarction atherosclerosis or sudden death
HistoryHistory
PhysicalPhysical
LaboratoryLaboratoryinfarction, atherosclerosis or sudden death.
• Angiographic studies have reported that the prevalencef di l b id i i 1 7 t ( 0 5 t 16
Laboratory Laboratory
Hospital Hospital CourseCourse
of myocardial bridging is 1.7 percent (range 0.5 to 16 percent), which is almost always confined to the LAD.
Left Heart Left Heart CatheterizationCatheterization
DiagnosisDiagnosis• A higher prevalence has been observed in patients withHypertrophic Cardiomyopathy and in recipients of cardiactransplants.
DiagnosisDiagnosis
DiscussionDiscussion
Clinical
MYOCARDIAL BRIDGINGVignette
HistorHistorIs generally benign with a 5-year-survival rate ranging from 85-98%.
HistoryHistory
PhysicalPhysical
LaboratoryLaboratory
Associated with:
Laboratory Laboratory
Hospital Hospital CourseCourse
1. Cardiac Ischemia
2 Atherosclerosis
Left Heart Left Heart CatheterizationCatheterization
DiagnosisDiagnosis2. Atherosclerosis
3. Hypertrophic Cardiomyopathy
DiagnosisDiagnosis
DiscussionDiscussion
Clinical
MYOCARDIAL BRIDGINGVignette
HistorHistor• Diagnosis
1. Angiography
HistoryHistory
PhysicalPhysical
LaboratoryLaboratoryg g p y
2. Others:
Laboratory Laboratory
Hospital Hospital CourseCourse
Doppler-flow catheterIVUSElectron beam CT
Left Heart Left Heart CatheterizationCatheterization
DiagnosisDiagnosisMultislice CTMagnetic Resonance TomographyTransthoracic doppler echocardiography
DiagnosisDiagnosis
DiscussionDiscussion
Clinical
MYOCARDIAL BRIDGINGVignette
HistorHistor• Management
1 Beta blockers
HistoryHistory
PhysicalPhysical
LaboratoryLaboratory1. Beta blockers
2. Calcium channel blockers
Laboratory Laboratory
Hospital Hospital CourseCourse
3. No nitratesLeft Heart Left Heart
CatheterizationCatheterization
DiagnosisDiagnosis4. No stents
5. Surgical therapy
DiagnosisDiagnosis
DiscussionDiscussion
Clinical
CONCLUSIONVignette
HistorHistor• This case illustrates the potential consequences of
intramyocardial bridging, including myocardial ischemia, as well as the clinical importance of suspecting this condition
HistoryHistory
PhysicalPhysical
LaboratoryLaboratorywhen a patient presents with intermittent episodes of severe chest pain that worsens with the administration of nitroglycerin.
Laboratory Laboratory
Hospital Hospital CourseCourse
• Although this clinical condition is rare and the treatment ismainly medical management, it is important to confirm thediagnosis with coronary angiography.
Left Heart Left Heart CatheterizationCatheterization
DiagnosisDiagnosis
• If the patient’s symptoms are refractory to medical management, or if they have a documented episode of a subsequent myocardialinfarction they may benefit from surgical intervention
DiagnosisDiagnosis
DiscussionDiscussion
infarction, they may benefit from surgical intervention.
REFERENCES
1. Möhlenkamp S, Hort W, Ge J, Erbel R. Update on myocardial bridging. Circulation 2002; 106:2616.
2 Alegria JR Herrmann J Holmes DR Jr Lerman A Rihal CS Myocardial bridging Eur2. Alegria JR, Herrmann J, Holmes DR Jr, Lerman A, Rihal CS. Myocardial bridging. EurHeart J 2005; 26:1159.
3. Noble J, Bourassa MG, Petitclerc R, Dyrda I. Myocardial bridging and milking effect of the left anterior descending coronary artery: normal variant or obstruction? Am Jof the left anterior descending coronary artery: normal variant or obstruction? Am J Cardiol 1976; 37:993.
4. Faruqui AM, Maloy WC, Felner JM, Schlant RC, Logan WD, Symbas P. Symptomatic myocardial bridging of coronary artery Am J Cardiol 1978; 41:1305myocardial bridging of coronary artery. Am J Cardiol 1978; 41:1305.
5. Morales AR, Romanelli R, Boucek RJ. The mural left anterior descending coronary artery, strenuous exercise and sudden death. Circulation 1980; 62:230.
6 Ishikawa Y Akasaka Y Suzuki K Fujiwara M Ogawa T Yamazaki K Niino H Tanaka M
REFERENCES
6. Ishikawa Y, Akasaka Y, Suzuki K, Fujiwara M, Ogawa T, Yamazaki K, Niino H, Tanaka M, Ogata K, Morinaga S, Ebihara Y, Kawahara Y, Sugiura H, Takimoto T, Komatsu A, Shinagawa T, Taki K, Satoh H, Yamada K, Yanagida-lida M, Shimokawa R, Shimada K, Nishimura C, Ito K, Ishii T. Anatomic properties of myocardial bridge predisposing to myocardial infarction. Circulation 2009; 120:376.
7. Utuk O, Bilge A, Bayturan O, Tikiz H, Tavli T, Tezcan U. Thrombosis of a coronary artery related to the myocardial bridging. Heart Lung Circ 2010; 19:481.
8. Hostiuc S, Curca GC, Dermengiu D, Dermengiu S, Hostiuc M, Rusu MC. Morphological changes associated with hemodynamically significant myocardial bridges in sudden cardiac death. Thorac Cardiovasc Surg 2011; 59:393.
9 H L Nk l R W lf M K f PA M di l b id i i9. Husmann L, Nkoulou R, Wolfrum M, Kaufmann PA. Myocardial bridging causing infarction and ischaemia. Eur Heart J 2011; 32:790.
10. Hongo Y, Tada H, Ito K, Yasumura Y, Miyatake K, Yamagishi M. Augmentation of vessel squeezing at coronary myocardial bridge by nitroglycerin: study by quantitative coronarysqueezing at coronary-myocardial bridge by nitroglycerin: study by quantitative coronary angiography and intravascular ultrasound. Am Heart J 1999; 138:345.
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