A 57 year Old Man With Hypertension And History Of Smoking Presents With Complains Of Pressure Like Sensation In His Chest.

A 57-year-old automobile salesman who is hypertensive and a heavy cigarette smoker describes a pressure-like sensation that developed for the first time 3 weeks before. The discomfort, which begins in the retrosternal area, radiates to the left side of his lower jaw, occurs when he walks rapidly in cold air, and more recently occurs at rest.
Careful history reveals that it lasts for 10 to 15 minutes, but an especially severe episode awakened him the night before and lasted nearly half an hour before resolving spontaneously.
Except for a bloodpressure of 150/100 mm Hg, the physical examination findings are normal.
An ECG (obtained after the pain has disappeared) reveals deep and symmetric T wave inversion in leads V1 to V4. The patient is admitted and given IV heparin and oral aspirin.

1. What is your diagnosis?
2. What are some common physical findings during an ischemic episode?

Approximately 4 hours after admission, the patient again experiences transient chest pressure. You order an ECG. The T waves are now upright in leads V1 to V4.

3. What are these ECG changes called, and what do they represent?
4. How should the recurrent chest pain be treated?
5. What should be done next?

Answers:


1. What is your diagnosis?
This patient has either unstable angina or an NSTEMI. The pain is both new in onset and occurs at rest. The T-wave inversions confirm the diagnosis of ischemia. The results of cardiac enzyme tests separate unstable angina (negative enzymes) from NSTEMI (positive enzymes).

2. What are some common physical findings during an ischemic attack?
Increases in heart rate and blood pressure are the most common findings during ischemia. Physical examination performed during an ischemic attack may reveal an S4 or a murmur of mitral regurgitation. If the ischemic area is large then an S3, pulmonary rales, a dyskinetic apical impulse, and hypotension could be noted. Ischemia decreases left ventricular compliance (increased “stiffness”) with subsequent increase in left ventricular filling pressure. The resistance to filling during atrial contraction is what produces the S4 sound. How ever, an S4 is a nonspecific finding and is frequently heard in older adults. Localized contraction abnormalities may produce transient papillary muscle dysfunction and failure of complete apposition of the leaflets, resulting in mitral regurgitation. Similar contraction abnormalities can cause an outward bulge of the left ventricle with dyskinetic apical impulse. This can be felt by using the palm of the hand while the patient is in the left lateral decubitus position.

3. What are these ECG changes called, and what do they represent?
When previously inverted T waves become upright in the presence of chest pain, it is called pseudonormalization. This is strongly suggestive of ischemia.

4. How should the recurrent chest pain be treated?
The pseudonormalization of the T waves clearly indicates myocardial ischemia. This pain should be treated with sublingual NTG and IV morphine, followed by IV NTG and β-blockade if there are no contraindications. The patient is already receiving aspirin and heparin (low -molecular-weight heparin can also be used in this case). Platelet glycoprotein IIb/IIIa inhibitors are of value in the treatment of high-risk patients with unstable angina/NSTEMI. Statins have been shown to reduce cardiac event rates when used acutely in this population. If the patient is not a candidate for coronary artery bypass graft (CABG), then clopidogrel should be considered.

5. What should be done next?
This patient had signs of myocardial ischemia on admission with recurrent pain on IV heparin. This is suspicious for the presence of substantial ischemia, and the deeply inverted T w aves in leads V1 to V4 mostly likely represent a high-grade proximal LAD stenosis. This patient should undergo coronary angiography. PCI should be performed in general for one- or two vessel disease and normal or near-normal left ventricular function. For most patients with three-vessel disease or left ventricular dysfunction, especially in the presence of diabetes, coronary artery bypass surgery (using w henever
possible an internal mammary artery graft to the LAD) is indicated. The use of PCI versus coronary bypass surgery may vary depending on patient or physician preference, lesion anatomy, the presence of proximal LAD disease, or the patient's comorbidities.