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Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine

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1 Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine

2 Medical Grand Rounds Clinical Vignette December 17 th, 2008 Anjali Grover, M.D.

3 Chief Complaint A 45 year old Hispanic male presents with chest pain for 45 minutes.

4 History of Present Illness The patient was well until the evening of admission when he had the sudden onset of non-radiating, sub-sternal chest pressure while walking. The chest pain was associated with shortness of breath, light-headedness, palpitations, diaphoresis and nausea without vomiting.

5 Additional History Past Medical History: –Hyperlipidemia –Depression Past Surgical History: none Social history: –Current smoker with a 25 pack year history –Denies ethanol or illicit drug use Family History: –Mother died of a myocardial infarction at age 76 Allergies: –No known drug allergies Medications: -- Simvastatin 40 mg daily -- Aspirin 81 mg daily -- Fluoxetine 20 mg daily

6 Physical Exam General: In mild distress appearing anxious secondary to chest pain, appeared his stated age. T:97.1 o F BP:159/82 HR:84 RR:16 O:97%RA T:97.1 o F BP:159/82 HR:84 RR:16 O 2 :97%RA The remainder of the physical exam was normal

7 Laboratory Basic Metabolic Panel normal Complete Blood Count normal Hepatic Function Panel normal Time 0 hoursTime 8 hours Troponin0.09 (normal <0.07)0.01

8 Imaging ECG: Sinus rhythm with rate of 63, 2 mm ST elevation in V2, 1 mm up-slanting ST depression in II, III, aVf. Chest X-Ray: No evidence of pulmonary congestion, infiltrate or effusions.

9 Working Diagnoses Acute Coronary Syndome: ST Elevation Myocardial Infarction (STEMI) Brugada Syndrome

10 Hospital Course Emergency Room course: –Treated with: Aspirin 325mg Clopidogrel 300mg Lopressor 5 mg IVP x 3 Morphine 4mg IVP Sub-lingual Nitroglycerine 0.4mg x 3 Heparin drip Lipitor 80 mg The patient remained hemodynamically stable, EKG changes were stable and his chest pain resolved.

11 Hospital Course Hospital Day #1:   Cardiac Catheterization revealed clean coronary arteries   Transthoracic Echocardiogram showed no abnormalities Hospital Day #2:   Procainamide challenge performed to evaluate for possible manifestations of Brugada Syndrome on EKG.   With procainamide, the patient’s 2mm “saddle-back” ST segment elevation in V2 converted to a “coved” ST segment elevation pattern.   These findings represented a positive procainamide challenge.

12 Hospital Course Hospital Day #3:  Electrophysiology Study performed for further risk stratification revealed no inducible ventricular arrhythmias. Intracardiac defibrillator placement was recommended to the patient, but he refused. He was discharged on Aspirin and Zocor. 6 months later on follow-up in Cardiology Clinic, the patient agreed to ICD placement. It was placed shortly thereafter.

13 Final Diagnosis Type 2 Brugada Syndrome

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