A 67 Year Old Woman With Known Diabetes And Hypertension Presents With Severe shortness of Breath - Case Study

A 67-year-old woman is in town visiting her children when she presents to your office complaining of severe symptoms of shortness of breath that has worsened over the last 12 hours. She tells you that she has had diabetes mellitus for the last 20 years and hypertension that has been fairly well controlled for 15 years.
Your examination reveals an S3 gallop and rales to her midscapular area. She also tells you that she has experienced recurrent chest heaviness over the last 2 days. When the ECG is done, there are Q waves in leads V2, V3, V4, and V5. A call to her regular physician reveals she had a normal ECG when he saw her 1 month ago.

Answer the following questions:
1. At this point, what should you do?
2. What therapeutic interventions should be instituted at the time of admission?
3. Before discharge, she has an echocardiogram performed. What findings would favor long-term anticoagulant therapy with sodium warfarin?
4. Should this patient undergo coronary angiography or should she have a submaximal exercise test?
5. Would you recommend PTCA, surgery, or medical therapy?

Answers:

1. At this point, what should you do?
Your patient has had a recent anterior MI w ith left ventricular failure causing her symptoms. She needs to be hospitalized immediately, treated for HF, monitored for arrhythmias and recurrent ischemia, and risk-stratified. Thrombolytic therapy or PCI is not indicated because this is a completed
infarction, nearly 48 hours old.


2. What therapeutic interventions should be instituted at the time of admission?
Initial treatment consists of oxygen administration for hypoxemia and diuresis while avoiding hypokalemia. The goal of diuresis is to resolve pulmonary congestion. Aspirin should be started. Telemetry monitoring is necessary to detect arrhythmias. ACE inhibitors (or an ARB if allergic) should be started if the patient is not hypotensive and has no contraindications to their use.
Aldosterone blockers should be introduced. Heparin should be considered in this patient with a large anterior MI because of the risk of left ventricular apical thrombus formation and embolism. A β-blocker should be considered only after resolution of the patient's symptoms of HF.

3. Before discharge, she has an echocardiogram performed. What findings would favor long-term anticoagulant therapy with sodium warfarin?
An apical thrombus, especially if mobile, increases the risk of embolism and is considered an acceptable indication for anticoagulation. The same is true of a dyskinetic or akinetic ventricular segment. In these cases, warfarin is continued for 3 to 6 months or until a thrombus is no longer present. How ever, these recommendations are not based on prospective randomized trials.
Two clear indications for anticoagulation in this setting are the presence of atrial fibrillation or a history of a previous embolic episode.

4. Should this patient undergo coronary angiography or should she have a submaximal exercise test?
This woman presented with a large MI and HF suggesting severe CAD. Her mortality risk is high and therefore exercise testing for risk stratification is not necessary. She should therefore be evaluated directly with coronary angiography.

Coronary angiography show s a 90% proximal right coronary artery obstruction, a 90% proximal left anterior descending (LAD) obstruction, and a 100% proximal circumflex obstruction. Her EF by left ventricular angiography is 34%, with moderate anterior hypokinesis.

5. Would you recommend PTCA, surgery, or medical therapy?
With severe three-vessel disease and left ventricular dysfunction, coronary artery bypass surgery is indicated in this patient. The presence of diabetes favors surgery over PTCA in this particular case even if the EF is not low.