Case Discussion CASE REPORT This 66-year-old man , a heavy smoker, complained of chest pain for two days, which was characterized as compressive over retrosternal area, and relieved spontaneously after resting for few minutes. He did not pay attention to it initially, but the pain still bothered him on the following day. He visited LMD, the symptom was slightly improved after unknown medication injection. Unfortunately, he felt that chest pain became progressive and was radiated to the back six hours prior to admission; dyspnea and cold sweating were happened subsequently. He was brought to local hospital for consultation. However, he was referred to our hospital immediately due to critical condition. He does not have any systemic disease such as DM, hypertension, or hyperlipidemia. He took three cups of herb wine (藥酒) per day for half a year. No sickness was mentioned recently. At ER, his consciousness was clear, BP-86/48 mmHg, heart rate- 82 beats/min, respiration rate- 16 cycles/min, and body temperature- 36.8°C. Oxygen saturation was 96% by Oxymeter measurement Neck was supple. Jugular vein was not engorged. Symmetrical chest expansion with clear breath sound, regular heart beat without heart murmur, soft abdomen without bruit sound, and intact symmetrical pulsation over all extremities were found Also, neurological examination was normal. EKG(Fig.1) was performed. CBC: WBC(K/μL) RBC (M/μL) HB( g/dL) HCT( %) MCV( fL) 10.37 3.62 11.1 30.6 84.5 MCH (pg) MCHC(g/dL) PLT(K/μL) Blast(%) Promyl(%) 30.7 36.3 60.0 0.0 0.0 Myelo(%) Meta(%) Band(%) Seg(%) Eos(%) Baso(%) 7.0 5.0 6.0 65.0 0.0 1.0 BCS: Alb (g/dL) D-BIL(mg/dL) T-BIL(mg/dL) LDH(mg/dL) UN(mg/dL) 3.1 1.1 1.7 445 22 CRE(mg/dL) Na(mmol/L) K(mmol/L) Mg(mmol/L) P(mmol/L) 1.3 142 4.7 1.32 6.2 CK(U/dL) CK-MB Troponin-I     1113 127 30     CASE ANALYSIS 66歲男性病人，因持續胸痛兩天，合併呼吸困難及盜汗，被送至醫院急診室。到院時，病人意識清楚，血壓86/48 mmHg，頸靜脈平坦，肺部無囉音；心電圖顯示lead I, aVL, and V2的ST升高併LBBB pattern，同時生化學檢查心肌酵素亦升高(CK: 1113 U/dL, CK-MB: 127 U/dL, Troponin I: 30)。所以，馬上診斷是急性心肌梗塞。除給予normal saline and Dopamine infusion 外，還裝置intra-aortic ballon counterpulsation (IABP) 來維持血壓的穩定。然而，病人持續感到胸悶，且血壓仍不穩定，立即安排緊急心導管檢查。在心導管檢查中，發現冠狀動脈是正常的；另外，心電圖亦出現不同的 interventricular conduction disturbance( LBBB →RBBB)。就急性心肌梗塞的心電圖變化若合併正常冠狀動脈攝影時，應高度懷疑是急性心肌炎(acute myocarditis)。此時，需做右心室切片檢查來確定診斷。若病況仍持續惡化，就需裝置extracorporeal membrane oxygenation (ECMO)來降低心肌的病變，同時給予Intravenous Immunoglobulin (IVIG) 1 mg/Kg/day來治療acute myocarditis。如果，上述治療失敗，唯有換心一途。 繼續教育考題 1. (D) What is your initial diagnosis from patient’s symptoms, EKG, and BCS data? A Pericarditis. B Pulmonary embolism. C Endocarditis. D Acute myocardial infarction. E Aortic dissection. 2. (A) Blood pressure was dropped to 70/50 mmHg, but patient’s consciousness was clear. What will you do now? a. Normal saline fast infusion. b. Nitroglycerin (NTG) infusion. c. Dopamin infusion. d. Dobutamine infusion. e. Endotracheal tube insertion. A a + c B b + c C b + d D c + e E d + e 3. (C) Systolic blood pressure was around 85-92 mmHg under intra-aortic ballon counterpulsation (IABP) support, but chest pain was not relieved. What will you do now? A Give sublingual NTG. B Increase inotropic agent dose. C Emergent cardiac catheterization. D Consult surgeon for heart transplant. E Add Glycoprotein IIb/IIIa receptor antagonist administration. 4. (C) Please see a series of ECG: Fig. 1- admission, Fig. 2- one hour after admission, Fig 3.- 12 hours after admission. Systolic blood pressure was kept at 90- 100 mmHg. Consciousness was not changed. Electrolytes and ABG were under normal ranges. What will you do? A Do electrophysiological study (EPS) B Digoxin administration C Temporal pacemaker insertion D Using Automated External Defibrillator (AED) E Beta-blocker administration 5. (B) Normal coronary arteries were found by coronary angiography. Left ventricle angiography revealed ejection fraction-44% and hypokinesia over anterior wall. Which impression will be considered from the catheterization report and a series of ECG changes in Question 4? A Pericarditis B Myocarditis C Endocarditis D Pulmonary embolism E Aortic dissection. 6. (C) Which non-invasive examination will be fast to help you get correct diagnosis from Question 5 (A-E)? A Chest CT B Radionuclide study C Cardiac sonography. D 24-hour Holter E Perfusion-ventilation lung scan 7. (C) Which invasive examination will be considered from Question 5? A Do electrophysiological study (EPS) B Pulmonary angiography C Right ventricle biopsy D Do transesophageal echo (TEE) E Pericardiocentesis 8. (D) Swan-Ganz catheter data: Cardiac Output- 2.2 L/min (N: 2.5-4.0), Pulmonary capillary wedge pressure- 16 mmHg , Systemic vascular resistance- 2031 dyne/sec/cm-5 (N: 900-1300), Pulmonary vascular resistance-206 dyne/sec/cm-5 (N: 155-255). What is your interpretation? A Hypovolemic shock B Neurologic shock C Septic shock. D Cardiogenic shock. E None 9. (D) Patient’s condition became poor gradually. What treatment will be suggested? A Keep intra-aortic ballon counterpulsation (IABP) support B Continue inotropic agents administration C Place an implantable defibrillator (ICD) because of the high likehood of ventricular tachycardia D Set up extracorporeal membrane oxygenation (ECMO) E Repeat coronary angiography for the possibility of coronary artery occlusion 10. (B) Patient’s condition became poor even after Intravenous Immunoglobulin (IVIG) 1 mg/Kg/day administration for two days. What treatment will be suggested? A Increase IVIG dose B Heart transplant C Continue inotropic agent infusion D Add Glycoprotein IIb/IIIa receptor antagonist administration E Do blood culture and give broad spetrum of antibiotics