case 28 2010 a 32 year old woman 3 weeks post partum with
play

Case 28-2010: A 32-Year-Old Woman, 3 Weeks Post Partum, with Substernal Chest Pain C A S E S T U D Y P R E S E N T E D B Y : L A U R E N S H I R L E Y , A L L I S O N O C O N N O R A N D C A L R O B B I N S Medical History 3

0 downloads 1 Views 852 KB Size Report
  1. Case 28-2010: A 32-Year-Old Woman, 3 Weeks Post Partum, with Substernal Chest Pain C A S E S T U D Y P R E S E N T E D B Y : L A U R E N S H I R L E Y , A L L I S O N O ’ C O N N O R A N D C A L R O B B I N S

  2. Medical History — 3 weeks postpartum — First pregnancy: hypertension and preeclampsia — Normal blood pressure between pregnancies — Second pregnancy: ¡ 1st trimester BP: 120-140/60-80 ¡ 2nd trimester BP: 118-120/60-82 ¡ 3rd trimester BP: 104-130/60-78 ¡ Postpartum BP: 120/80 ¡ Undersized placenta (340 grams) with increased perivillous fibrin — No medications or allergies

  3. Family and Social History — Family History ¡ Parents: hypertension, hyperlipidemia ¡ Distant Cousin: stroke — Social History ¡ Profession: physician ¡ Lives with husband, toddler, and newborn ¡ No use of alcohol, illicit drugs, or tobacco

  4. Onset — 7:25 PM ¡ Patient developed left jaw and substernal chest pain ¡ Pain resolved spontaneously — 8:00 PM ¡ Chest pain returned ¡ EMS called, pain resolved after 20 min O 2 therapy

  5. Onset (Continued) — 8:26 PM ¡ Pain returned (7/10) with shortness of breath ¡ EMS returned ÷ BP: 148/74 mm Hg ÷ Pulse: 90-100 bpm ÷ Interventions: Oxygen, 325mg Aspirin, Nitroglycerin (x3), Morphine 4mg ¡ Pain resolved en route, arrived at ED 8:50P

  6. Physical Exam — Vital Signs ¡ Blood Pressure: 143/92 mm Hg on left, 137/81 mm Hg on right ¡ Heart Rate: 83-92 bpm ¡ Neck: jugular vein distension (JVP 6-7 cm H2O) ¡ Cardiovascular: no murmurs, rubs, or gallops

  7. Labs — ECG: ¡ Normal sinus rhythm ¡ Incomplete right Bundle Branch Block ¡ ST elevation in V2, V3 — CK MB and Troponin I were negative — Electrolytes were normal

  8. Diagnostic Process — Chief Complaint: Substernal Chest Pain, Radiating to Jaw — Possible Causes of Chest Pain: ¡ Cardiovascular ¡ Pulmonary ¡ Gastrointestinal ¡ Musculoskeletal

  9. Shows coronary artery dissection in the mid-to-distal left anterior descending artery (35mm long segment of narrowing, 90% stenosis)

  10. Coronary Angiography-LAD Day 0

  11. What is a coronary artery dissection? — Tear in the coronary artery ¡ Inner and outer layer of the artery separate ¡ Blood pools in the area between the layers — Tear can slow and/or block blood flow to the heart causing a heart attack, abnormalities in heart rhythm or sudden death — Symptoms ¡ Chest Pain ¡ Rapid HR; fluttery feeling in chest ¡ Pain in arms, shoulder or jaw ¡ Shortness of breath ¡ Sweating ¡ Unusual tiredness ¡ Nausea ¡ Dizziness

  12. Postpartum Coronary Artery Dissections — 75% of postpartum SCAD occur 1 day to 3 months postpartum (most occur within first 2 weeks) — Mean age 33 y/o — 87% occur in left coronary tree

  13. Idiopathic Spontaneous Coronary Artery Dissection — 75% pt’s female, premenopausal with no traditional cardiac risk factors — 80% occur in left coronary tree — Precipitated by activities that cause coronary shear stress ¡ severe systolic hypertension ¡ cocaine use, snow shoveling ¡ weight lifting, etc. ¡ As well as seemingly benign stresses such as running, aerobics, sneezing, etc. — Pt.’s chest pain began right after picking up toddler

  14. Treatment — There is no consensus on appropriate treatment — Case dependent — Usually a conservative approach is taken

  15. Conservative Treatments — Patients who are stable and pain free — Cardiac Support ¡ Blood Thinners and Nitrates ¡ Intra-aortic Balloon Pump

  16. Interventional Treatments — Patients with major or continued ischemia ¡ Percutaneous Coronary Intervention (PCI) ¡ Coronary Artery Bypass Grafting (CABG)

  17. Case Treatment Decisions — Patient Information ¡ Left Anterior Descending Artery Dissection ¡ No Pain ¡ Slight Cardiac Ischemia

  18. Case Treatment Decisions — Conservative Medical Treatment ¡ Intra-aortic Balloon Pump ¡ β - blockers ¡ Antiplatelet Agents (Aspirin) ¡ Anticoagulation Agent (Heparin) — Glycoprotein IIb/IIIa was not immediately administered

  19. Resolution — After 48hours ¡ Improved blood flow ¡ Dissection resolved ¡ Intra-aortic Pump Removed 2 Days

  20. Resolution — Discharged after 8 days with the following regimens: ¡ Warfarin, Atenolol, Simvastatin, Clopidogrel (discontinue after one year) ¡ Aspirin (indefinitely) 90 Days

  21. Pathology — 42-85% of cases involve Adventitial Inflammation due to Eosinophils — Eosinophils release histolytic agents which cause dissections in coronary arteries

  22. Cross Section of Ischemic Heart í

  23. Questions? Case Study Citation: Sabatine, Marc S., Farouc A. Jaffer, Paul N. Statts, and James R. Stone. "Case 28-2010: A 32-Year-Old Woman, 3 Weeks Post Partum, with Substernal Chest Pain." The New England Journal of Medicine (2010): n. pag. Web.

Recommend Documents


rady 401 case presentation
RADY 401 Case Presentation Ed. John

RADY 401 Case Presentation Ed. John Lilly, MD An 86-year-old woman presenting

role of care coordination of post partum w om en in hi v
Role of Care Coordination of Post

Role of Care Coordination of Post Partum W om en in HI V Care Brian

rain clinicopathologic
RAIN Clinicopathologic ID: 74 year old

2/16/2018 Case RAIN Clinicopathologic ID: 74 year old Chinese woman with

dr leslie
Dr. Leslie Saturday Seminar Unknown

Dr. Leslie Saturday Seminar Unknown Case Case History A 47 year old woman is

unusual tumors of the thyroid case 4
Unusual Tumors of the Thyroid: Case 4

Unusual Tumors of the Thyroid: Case 4 Theresa Scognamiglio, M.D. Assistant

a comprehensive intervention model to improve post partum
A COMPREHENSIVE INTERVENTION MODEL TO

A COMPREHENSIVE INTERVENTION MODEL TO IMPROVE POST -PARTUM IUD SERVICES IN

clinical history
Clinical History A 59-year-old woman

IAP Congress Jordan Mimics of Neoplasia in the GI tract Clinical History A

case 1
Case 1 Illuminating Consultation 44

5/25/2013 Case 1 Illuminating Consultation 44 year old woman with a mass in

case presentation
CASE PRESENTATION DR. SUKESH P V

CASE PRESENTATION DR. SUKESH P V EMERGENCY MEDICINE FINAL YEAR POST-GRADUATE

donald grandis m d a real life case presentation
Donald Grandis, M.D, A Real Life Case

Donald Grandis, M.D, A Real Life Case Presentation M.F. is a 64 year old

updating systematic reviews
Updating Systematic Reviews: Stroke

Updating Systematic Reviews: Stroke Prevention in Atrial Fibrillation A

chest pain in the night
Chest pain in the night . ACCA 2017

Chest pain in the night . ACCA 2017 London P Goldstein Lille university

refer to pharmacy
Refer to Pharmacy Pati tient su

Refer to Pharmacy Pati tient su support with ith medic icatio ions aft

clopidogrel
CLOPIDOGREL A second-generation

P he hen G en ene P 2 Y 12 12 T es est 1 CLOPIDOGREL A second-generation

navigating thrombosis and bleeding at the intersection of
NAVIGATING THROMBOSIS AND BLEEDING AT

NAVIGATING THROMBOSIS AND BLEEDING AT THE INTERSECTION OF ATRIAL FIBRILLATION

dual antiplatelet therapy in cabg to bleed or not to bleed
Dual Antiplatelet Therapy in CABG: To

Dual Antiplatelet Therapy in CABG: To Bleed? or Not To Bleed!!! CV Surgery

the role of pharmacokinetic and pharmacodynamic
The Role of Pharmacokinetic and

The Role of Pharmacokinetic and Pharmacodynamic Measurements in the Use of

cardiogenic shock algorithm and case presentation scai
Cardiogenic Shock Algorithm and Case

Cardiogenic Shock Algorithm and Case Presentation SCAI SHOCK - 2018 Jaya

lessons from the ta taste
Lessons from the TA TASTE STE trial

Lessons from the TA TASTE STE trial Prospective Registry based Randomized

1 2 3 this diagram shows the essence of management which
1 2 3 This diagram shows the essence

1 2 3 This diagram shows the essence of management which serves as a basis

switch of anti platelets for whom and how switch des aap
Switch of Anti-Platelets: for whom and

Switch of Anti-Platelets: for whom and how? Switch des AAP: pour qui et

what goes together peanut butter amp jam cookies amp milk
What Goes Together: Peanut Butter

What Goes Together: Peanut Butter & Jam, Cookies & Milk Antiplatelets