Case Discussion <Brief History>       A 71 year old woman was admitted to hospital for recurrent chest pain and increasing shortness of breath for 3 hours. She had been hospitalized about 3 months ago for unstable angina, when ECG revealed biphasic T waves in leads V1 – V4 (Figure1 ). She had a past history of type 2 diabetes controlled on drugs and hypertension. She described daily symptoms of chest pain and dyspnea with mild to moderate exertion, and had woken on two occasions at night with similar symptoms. She had no other problems, her blood sugars were satisfactory (averaging 110 to 150 mg/dl), and she reported no other features of heart failure. She had never smoked, lived by herself and was normally fully independent. Her usual medications consisted of: aspirin 100mg once per day, glipizide 5mg three times per day, and diltiazem CD 180mg once per day.      Physical examination revealed an elderly lady in no distress at rest, with regular pulse 80 bpm, BP 140/80 with no postural drop, JVP elevated 3cm, mild ankle edema, third heart sounds with 2/6 pan-systolic murmur at the apex, and widespread crackles in the lung bases on chest auscultation. ECG (Figure2 ) at ER revealed tall ST segment elevation in leads V1 – V5, while CXR showed mild cardiomegaly with pulmonary venous congestion and small bilateral pleural effusions. Blood tests revealed mild normochromic anaemia (Hb 10.2 g/dl), elevated serum creatinine 1.6mg/dl, urea 28 mg/dl, potassium 4.9 mmol/l, and raised troponin-I to 10 U/I. Urinalysis shows 2+ proteinuria.      Under the impression of acute anteroseptal AMI, emergent cardiac catheterization was performed and coronary angiogram showed LM short & patent, RCA patent, proximal LAD total occlusion, proximal LCX 60% stenosis; ballooning dilatation with stenting for LAD was performed with flow restoration and 0% residual stenosis . The post-procedural course was rather smooth. However, dyspnea followed by collapse was noted 5th days after infarction. BP70/40mmHg, HR124/min, grade 3/6 pan-systolic murmur at the apex, and diffuse wheezing were noted. F/U 12-lead ECG showed sinus tachycardia and Q wave in V1-4. Meanwhile, biochemistry and ABG was shown as following: BUN/Cr 36/1.8 mg/dl, AST 43 U/I, Na/K/Cl 141.6/4.53/111mM, Ca 2.06 mM, P 5.9 mg/dl, Mg 1.13 mM, CK/CK-MB/Troponin-I 70/16/14.1U/I; ABGs pH/pCO2/pO2/HCO3/BE 7.31/19.7/181.3/9.7/-15.0. Echocardiography revealed a jet from LV apical septum to RV. Intra-arterial counter-pulsation and repair for ventricular septal rupture were done soon. She was discharged 4 weeks later with improved condition. Disscusion      這位婦人前次住院的病情符合 Wellen's syndrome 的臨床診斷，Wellen's syndrome的定義是有典型心絞痛的病史再加上心電圖胸前導程V1-4 (尤其是V2-3)出現雙相或倒置的T 波，則可高度預期有嚴重的近端左前降枝冠狀動脈狹窄。患者因而有發生大片前壁心肌梗塞或猝死的高危險性；所以不建議做運動心電圖等壓力性檢查，而是應該及早做心導管檢查並且處理血管狹窄的問題。本病例提醒我們不應該忽略掉這些心電圖變化或是僅以保守性藥物治療的方式處理這類病人，以免延誤病情，造成更大的傷害。 參考文獻: Wellens' Syndrome, Annals of Emergency Medicine, March 1999, Vol.33, No. 3, pp347-351. 繼續教育考題 1. (D) What is the likely ECG diagnosis shown in figure1? A Acute myocarditis B Acute pulmonary embolism C LVH D Wellen's syndrome 2. (D) Retrospectively, what would be your triage-management decision in her first hospitalization? A Send the patient home and arrange follow-up with his family doctor B Admit the patient to a chest pain observation unit to rule-out acute coronary syndrome C Admit the patient to a coronary care unit to rule-out an AMI D Ensure that the patient has an immediate coronary catheterization 3. (C) What is the short-term mortality rate in patients with acute chest pain syndrome who are incorrectly identified as having low risk, are dismissed from the emergency department, and subsequently suffer myocardial infarction? A Very similar to the rate in hospitalized patients B 5% C 25% D 50% 4. (B) Which of the following statements about initial presentation of suspected acute coronary syndrome is true? A Oxygen should be administered throughout the hospitalization, even when the oxygen saturation rate is above 92% B Beta-blocker therapy should be strongly considered for all patients C Calcium channel blockers are standard therapy D If the initial electrocardiogram is normal, it is unlikely that the patient has an unstable coronary syndrome 5. (C) Mechanical complication should be considered when she suffered from dyspnea and collapse several days after AMI except A Mitral regurgitation due to papillary muscle rupture B Ventricular septal rupture C Patent foramen ovalis D Cardiac tamponade 6. (D) In unstable angina, factors associated with a poorer prognosis include the following: A Prognosis is determined by the ability to control symptoms acutely, preventing progression to AMI. B Evidence of myocardial necrosis, as determined by elevated troponin I C Delays in angiography in patients at high risk D All above are included. 7. (B) ST-segment elevation myocardial infarction is usually caused by A Coronary vasospasm B Thrombus superimposed on preexisting atherosclerotic plaque C Embolism from aortic debris D Collagen vascular disease 8. (D) Which of the following medications is/are not useful in the management of acute myocardial infarction? A Nitroglycerin B Beta-blockers C Aspirin D Adriamycin 9. (A) Which of the following is not appropriate for early reperfusion therapy for ST-elevation segment myocardial infarction? A Hemodialysis B Alteplase C Tenecteplase D Emergency angioplasty 10. (D) What is true about ventricular septal rupture from myocardial infarction? A Prompt diagnosis and immediate cardiac support (IABP) is necessary to obtain a hemodynamic stabilization before surgical intervention. B Factors most associated with this complication were advanced age, anterior infarction, female sex, et al. C Mortality at 30 days is around 75% in patients of AMI complicated with ventricular septal rupture. D All above are true.