{"id":2637,"date":"2010-09-06T21:16:43","date_gmt":"2010-09-07T01:16:43","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?p=2637"},"modified":"2011-07-19T17:44:07","modified_gmt":"2011-07-19T21:44:07","slug":"whats-at-the-heart-of-this-patients-problem","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2010\/09\/06\/whats-at-the-heart-of-this-patients-problem\/","title":{"rendered":"What&#8217;s at the Heart of This Patient&#8217;s Problem?"},"content":{"rendered":"<p>The patient is a 53-year-old lawyer with no cardiac risk factors other than a 70 pack-year history of smoking. He has a known history of diverticulitis with prior gastrointestinal bleeding and presented with lightheadedness and bright red blood per rectum. Initial evaluation revealed a drop in his hematocrit from 43% to 39%. He underwent a colonoscopy the next morning and was found to have multiple diverticula and sigmoid irritation, but no obvious source of bleeding was identified. His initial electrocardiogram is shown below.<br \/>\n<a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/wp-content\/uploads\/sites\/7\/2010\/08\/EKG-1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-2709\" title=\"EKG 1\" src=\"http:\/\/blogs.nejm.org\/cardioexchange\/wp-content\/uploads\/sites\/7\/2010\/08\/EKG-1-300x225.jpg\" alt=\"\" width=\"300\" height=\"225\" \/><\/a><a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/wp-content\/uploads\/sites\/7\/2010\/08\/EKG-1.jpg\"><\/a><\/p>\n<p>The next day, the patient abruptly bled again and had a further drop in his hematocrit to 29%, with a blood pressure of 85\/50 mm Hg and a heart rate of 95 bpm. With this, the patient complained of mild chest pressure, and a repeat electrocardiogram was obtained.<br \/>\n<a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/wp-content\/uploads\/sites\/7\/2010\/08\/EKG-2.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-2710\" title=\"EKG 2\" src=\"http:\/\/blogs.nejm.org\/cardioexchange\/wp-content\/uploads\/sites\/7\/2010\/08\/EKG-2-300x225.jpg\" alt=\"\" width=\"300\" height=\"225\" \/><\/a><a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/wp-content\/uploads\/sites\/7\/2010\/08\/EKG-2.jpg\"><\/a><\/p>\n<p>The patient was seen by a surgeon, who recommended an elective partial colectomy. A pre-operative cardiology consult was obtained.<br \/>\n<a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/wp-content\/uploads\/sites\/7\/2010\/08\/EKG-3.jpg\"><\/a><a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/wp-content\/uploads\/sites\/7\/2010\/08\/EKG-3.jpg\"><\/a><\/p>\n<p>Questions:<\/p>\n<ul>\n<li>What is this patient\u2019s peri-operative risk?<\/li>\n<li>Would you recommend any further cardiac evaluation prior to a partial colectomy?<\/li>\n<li>Would you recommend peri-operative beta-blockade in this patient?<\/li>\n<\/ul>\n<p><strong>Response<\/strong><br \/>\n<strong><a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/members\/jamesfang\/\">James Fang, MD<\/a><\/strong><\/p>\n<p>This gentleman has developed unstable angina in the setting of hemodynamically significant gastrointestinal bleeding. His perioperative risk is very high by any criteria. I suspect he has severe, life-threatening ischemic heart disease that has been unmasked by his acute medical condition. Although immediate resuscitation with volume and blood products should be the initial strategy, he should undergo urgent coronary angiography to define the extent of his coronary artery disease, so that therapeutic options can be reviewed. The site of his bleeding also remains unclear; once his cardiovascular status is stabilized, a tagged red cell scan or even angiography can be performed to understand the exact nature of his bleeding. Beta blockade is relatively contraindicated in someone with recently stabilized hypovolemic shock.<\/p>\n<p><strong>Part II<\/strong><br \/>\n<strong><a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/members\/anjunohria\/\">Anju Nohria, MD<\/a><\/strong><\/p>\n<p>The patient was transfused with 3 units of packed red blood cells and had a follow-up hematocrit of 32%. Later that night, he became restless, removed his telemetry leads, and was found on the floor in ventricular fibrillation. He was electrically cardioverted and reverted to sinus rhythm, and an amiodarone drip was started. A post-resuscitation electrocardiogram was obtained.<\/p>\n<p><a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/wp-content\/uploads\/sites\/7\/2010\/08\/EKG-3.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-2708\" title=\"EKG 3\" src=\"http:\/\/blogs.nejm.org\/cardioexchange\/wp-content\/uploads\/sites\/7\/2010\/08\/EKG-3-300x225.jpg\" alt=\"\" width=\"300\" height=\"225\" \/><\/a><\/p>\n<p>The patient was hypotensive and was stabilized with norepinephrine therapy. An initial creatine phosphokinase returned at 310 U\/L, with an MB fraction of 45.3 ng\/mL. The troponin I was also elevated at 0.36 ng\/mL. Cardiology was urgently called again.<\/p>\n<p>Questions for discussion:<\/p>\n<ul>\n<li>What additional medical management would you recommend at this time?<\/li>\n<li>Would you take this patient to the cardiac catheterization laboratory prior to surgery?<\/li>\n<li>If a significant cardiac lesion was identified, what type of intervention would you recommend?<\/li>\n<\/ul>\n<p><strong>Response<\/strong><br \/>\n<strong><a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/members\/jamesfang\/\">James Fang,  MD<\/a><\/strong><\/p>\n<p>Medical management should include volume and blood resuscitation, as well as definition of the coronary anatomy. The ventricular fibrillation and QRS widening post-resuscitation would be concerning for a large burden of CAD. In light of this patient\u2019s life-threatening GI bleeding, the use of anticoagulants, antiplatelet agents, and even nitrates\/beta-blockers is contraindicated until his coronary anatomy is defined. The management of his coronary disease depends on the nature and burden of that disease. The most critical lesion could be treated with temporizing balloon angioplasty. If there is left main and\/or severe three-vessel CAD, an intra-aortic balloon pump could be used to stabilize his situation. At that point, other strategies to define his GI bleeding and subsequent therapies could be entertained.<\/p>\n<p><strong>Follow-Up<\/strong><br \/>\n<strong><a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/members\/anjunohria\/\">Anju  Nohria, MD<\/a><\/strong><\/p>\n<p>The patient remained hemodynamically stable. His cardiac enzymes continued to rise, with a peak troponin I of 3.85 ng\/mL, a peak creatine phosphokinase of 2667 U\/L, and an MB fraction of 373.8 ng\/mL. An echocardiogram revealed a left ventricular ejection fraction of 50%, with an end-diastolic dimension of 6.2 cm. He had inferior and inferolateral hypokinesis. The mitral valve appeared myxomatous, with a prolapsed anterior leaflet and a fixed posterior leaflet. There was a new posteriorly directed jet of severe mitral regurgitation.<\/p>\n<p>The patient was taken to the catheterization laboratory, where he was found to have multivessel coronary artery disease with 90% left main, 90% mid left anterior descending, 80% proximal left circumflex, and 95% right coronary lesions. His left ventricular end-diastolic pressure was 12 mm Hg with large \u201cv\u201d waves.<\/p>\n<p>He underwent surgical revascularization with a left internal mammary graft to the left anterior descending artery \u2014 and saphenous vein grafts to the first obtuse marginal and right coronary arteries. He also underwent mitral valve repair with a Carpentier-Edwards ring and plication of the anterior leaflet.<\/p>\n<p>He did well postoperatively from a cardiac standpoint. He continued to be guaiac-positive but had no frank bleeding. He was discharged home on a proton pump inhibitor and no aspirin or Coumadin.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>The patient is a 53-year-old lawyer with no cardiac risk factors other than a 70 pack-year history of smoking. He has a known history of diverticulitis with prior gastrointestinal bleeding and presented with lightheadedness and bright red blood per rectum. Initial evaluation revealed a drop in his hematocrit from 43% to 39%. He underwent a [&hellip;]<\/p>\n","protected":false},"author":685,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[312,311,271,310],"class_list":["post-2637","post","type-post","status-publish","format-standard","hentry","category-general","tag-beta-blockers","tag-bleeding","tag-risk-factors","tag-surgical-evaluation"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/2637","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/685"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=2637"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/2637\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=2637"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=2637"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=2637"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}