ACP FLORIDA CHAPTER CLINICAL VIGNETTE ORAL

ACP FLORIDA CHAPTER CLINICAL VIGNETTE ORAL PRESENTATION

Vertilio M. Cornielle, M.D. PGY-3

March 2nd, 2013

Mount Sinai Medical Center, Miami Beach

CORONARY MILKING: A RARE CAUSE OF CHEST PAIN AND ELEVATEDOF CHEST PAIN AND ELEVATED

CARDIAC ENZYMES

Clinical

CHIEF COMPLAINT: CHEST PAINVignette

HistoryHistory

• A 56 year-old woman from Mexico comes to the emergency

HistoryHistory

PhysicalPhysical

Laboratory Laboratory y g ydepartment complaining of anterior chest pain for approximately two hours.

yy

ImagingImaging

Hospital Hospital

• The pain was described as oppressive, 10/10 in intensity,radiating to her left arm and back, and associated with shortness of breath and palpitations.

CourseCourse

Left Heart Left Heart CatheterizationCatheterizationp p

• The pain gets worse lying down and improves by leaning forward.

DiagnosisDiagnosis

DiscussionDiscussion

Clinical Vignette

HistoryHistory

• Sh d i DOE PND l iti h t i

HistoryHistory

PhysicalPhysical

Laboratory Laboratory • She denies DOE, PND or pleuritic chest pain.

• She had similar pain one month previously while in Mexico.

yy

ImagingImaging

Hospital Hospital

• A complete cardiac evaluation was performed, includingECG, echocardiogram and an exercise stress test, that

CourseCourse

Left Heart Left Heart CatheterizationCatheterization

showed no findings suggestive of ischemia.DiagnosisDiagnosis


Clinical Vignette

HistoryHistory

• PAST MEDICAL HISTORY

1 Hypothyroidism

PhysicalPhysical

Laboratory Laboratory 1. Hypothyroidism

2. Hiatal Hernia

ImagingImaging

Hospital Hospital CourseCourse

• PAST SURGICAL HISTORY Left Heart Left Heart Cardiac Cardiac

CatheterizationCatheterization1. C-section x 3

2. Breast Implants

CatheterizationCatheterization

DiagnosisDiagnosis

DiscussionDiscussionscuss oscuss o

Clinical Vignette

HistoryHistory

• MEDICATIONS

1 L th i 25 d

PhysicalPhysical

Laboratory Laboratory

1. Levothyroxine 25 mg qd ImagingImaging


• ALLERGIESLeft Heart Left Heart

Cardiac Cardiac CatheterizationCatheterization

1. SulfasCatheterizationCatheterization

DiagnosisDiagnosis

DiscussionDiscussionDiscussionDiscussion

Clinical Vignette

HistoryHistory

FAMILY HISTORY

1 M th CAD d CABG 3

PhysicalPhysical


1. Mother: CAD and CABG x 3 ImagingImaging


• CHILDHOOD DISEASESLeft Heart Left Heart


1. NoneCatheterizationCatheterization

DiagnosisDiagnosis


Clinical Vignette

HistoryHistoryINFECTIOUS DISEASES

1. None

HistoryHistory

PhysicalPhysical


• SOCIAL AND MARITAL HISTORY

yy

ImagingImaging

Hospital Hospital

1. Lives in Mexico with husband and her 3 daughters.

2. Housewife, currently on vacation with her family.

CourseCourse


3. Previous smoker, 1 PPD for approx. 30 yrs. Quit 8 yrs ago.

4 Drinks an occasional glass of wine no drugs

DiagnosisDiagnosis

DiscussionDiscussion4. Drinks an occasional glass of wine, no drugs.

Clinical Vignette

HistoryHistory

REVIEW OF SYSTEMS

E d i + h t ld i t l l i

PhysicalPhysical


Endocrine: + heat or cold intolerance no polyuria orpolydipsia.

ImagingImaging


Cardiovascular: + chest pain and palpitations, no DOE, PND

Respiratory: No cough pleuritic chest pain or + SOB

Left Heart Left Heart Cardiac Cardiac

CatheterizationCatheterizationRespiratory: No cough, pleuritic chest pain or + SOB.

Rest of the review of system is unremarkable.


DiagnosisDiagnosis


Clinical Vignette

HistoryHistory

Physical Exam:

Vitals: Temp: 98 3 BP: 102/58 HR: 74 (SR) RR: 18

PhysicalPhysical

Laboratory Laboratory Vitals: Temp: 98.3 BP: 102/58 HR: 74 (SR) RR: 18

General Appearance: good appearance, well hydrated.

ImagingImaging


HEENT: PERRL, NL EOM. Left Heart Left Heart Cardiac Cardiac

CatheterizationCatheterizationSkin: No lesions or rashes.

Neck: No JVD, no carotid bruits no masses.


DiagnosisDiagnosis


Clinical Vignette

HistoryHistory

Thorax: Normo-dynamic, no deformities. PhysicalPhysical


Breast: No masses, no skin changes and no drainage.ImagingImaging


Lungs: CTA Bl, no abnl BS. Left Heart Left Heart Cardiac Cardiac


Cardiac: regular rhythm, nl s1 and s2, no murmurs,rubs or gallops.


DiagnosisDiagnosis


Clinical Vignette

HistoryHistory

Abdomen: Soft, NT, ND + BS, no masses. PhysicalPhysical


Genitourinary: No CVA tenderness.ImagingImaging


Extremities: nl pulses, no edema.Left Heart Left Heart


Lymph Nodes: No lymphadenopathy.


DiagnosisDiagnosis


Clinical Vignette

HistoryHistory

Musculoskeletal: No deformities, joint tenderness, swellingff i

PhysicalPhysical


or effusions. ImagingImaging


Neurological: CN II-XII intact, with no motor deficits or sensory deficits Gait wnl and DTR unable to evaluate at


CatheterizationCatheterizationsensory deficits. Gait wnl and DTR unable to evaluate at the time.


DiagnosisDiagnosis


Clinical DIAGNOSTIC STUDIES

PERFORMED IN THE ERVignette

HistoryHistory

141 107 1212 0

PhysicalPhysical

Laboratory Laboratory 141

4.1

107

27

12

0.44 1067.2812.0

36.7157 ImagingImaging


TSH 0.005

Cholest 99 trig 46 HDL 32

CKMB 1st 0.5

CPK 63

CourseCourse


C th t i tiC th t i tiCholest 99, LDL 58

trig 46, HDL 32Trop 0.092


DiagnosisDiagnosis


Clinical DIAGNOSTIC STUDIES

PERFORMED IN THE ERVignette

HistoryHistoryHistoryHistory

PhysicalPhysical

LaboratoryLaboratoryLaboratory Laboratory

ImagingImaging

Hospital Hospital ppCourseCourse

AngiographyAngiography

DiagnosisDiagnosis


Clinical

DIFFERENTIAL DIAGNOSISVignette

CHEST WALL PAIN

1. Musculoskeletal pain

2. Isolated musculoskeletal chest pain syndromes

3. Rheumatic diseases

GASTROINTESTINAL CAUSES OF CHEST PAIN

1. Gastroesophageal reflux disease

2. Esophageal hyperalgesia

3. Abnormal motility patterns and achalasia

4. Nonrheumatic systemic diseases

5. Skin and sensory nerves

CARDIAC CAUSES OF CHEST PAIN

4. Esophageal rupture, mediastinitis, and foreign bodies

5. Medication-induced esophagitis

6. Other gastrointestinal causes of chest pain

1. Coronary heart disease

2. Aortic dissection

3. Valvular heart disease

PULMONARY CAUSES OF CHEST PAIN

1. Pulmonary vasculature

2. Acute pulmonary thromboembolism

3. Pulmonary hypertension and cor pulmonale

4 Lung parenchyma4. Pericarditis

5. Myocarditis

6. Stress-induced cardiomyopathy

7. Cardiac syndrome X

4. Lung parenchyma

5. Pneumonia

6. Cancer

7. Sarcoidosis

8. Pleura and pleural space8. Pheochromocytoma

PSYCHOGENIC/PSYCHOSOMATIC CAUSES OF CHEST PAIN

9. Pneumothorax

10. Pleuritis/serositis

11. Pleural effusion

12. Mediastinal disease

Clinical

HOSPITAL COURSEVignette

HistoryHistory

• In the emergency department the patient had an ECGperformed that showed normal sinus rhythm and possible left atrial enlargement but no ST segment or T wave abnormalities suggesting

PhysicalPhysical


ischemia.

• CTA performed showed no signs of PE, Ao dissection or

Hospital CourseHospital Course

ImagingImaging

L f HL f HPNA.

• Patient was then admitted to the telemetry floor and was t t d NSTEMI


CatheterizationCatheterizationtreated as a NSTEMI.

• Echocardiogram, repeat ECG’s and subsequent two sets oftroponins trended down to normal

DiagnosisDiagnosis

DiscussionDiscussiontroponins trended down to normal.

Clinical


HistorHistor• However on day 2 of hospitalization the patient again

complained of severe precordial chest pain, this time d i h h d i i i f i l i

HistoryHistory

PhysicalPhysical

LaboratoryLaboratoryworsened with the administration of nitroglycerin. Laboratory Laboratory

Hospital CourseHospital Course

ImagingImaging• Repeat Troponin and CK MB were elevated at 0.611

and 4.7 respectively, without any changes on ECG’s.

g gg g


• Left heart catheterization was performed that showed:

DiagnosisDiagnosis


Clinical LEFT HEART CARDIAC

CATHETERIZATIONVignette

HistorHistorHistoryHistory

PhysicalPhysical




DiagnosisDiagnosisDiagnosisDiagnosis


Clinical LEFT HEART CARDIAC

CATHETERIZATIONVignette


PhysicalPhysical






Clinical


HistorHistor

• Left Heart Catheterization results: myocardial b id i f h i l l f i d di

HistoryHistory

PhysicalPhysical

LaboratoryLaboratorybridging of the proximal left anterior descending coronary artery with no evidence of obstructive disease.



• No intervention was performed and the patient was


DiagnosisDiagnosis• No intervention was performed and the patient was discharged home and managed medically with aspirin and calcium channel blockers.

DiagnosisDiagnosis


Clinical

CORONARY BRIDGING Vignette


PhysicalPhysical






Clinical

MYOCARDIAL BRIDGINGVignette

HistorHistor• Coronary arteries occasionally have a segmental

intra-myocardial course.

D i l hi f h l i d

HistoryHistory

PhysicalPhysical

LaboratoryLaboratory• During systole, this segment of the vessel is compressed, a condition referred to as milking or systolic "myocardialbridging".



• This phenomenon was first recognized more than 200 years ago by Reyman, HC. Disertatis de vasis cordis propiis. Bibl Anat.1737;2:366.


DiagnosisDiagnosis

• First reported in depth in 1951.

• First recognized angiographically in 1960

DiagnosisDiagnosis


First recognized angiographically in 1960.

Clinical


HistorHistor• Severe bridging of the major coronary arteries can produce

myocardial ischemia, coronary thrombosis, myocardial infarction atherosclerosis or sudden death

HistoryHistory

PhysicalPhysical

LaboratoryLaboratoryinfarction, atherosclerosis or sudden death.

• Angiographic studies have reported that the prevalencef di l b id i i 1 7 t ( 0 5 t 16



of myocardial bridging is 1.7 percent (range 0.5 to 16 percent), which is almost always confined to the LAD.


DiagnosisDiagnosis• A higher prevalence has been observed in patients withHypertrophic Cardiomyopathy and in recipients of cardiactransplants.

DiagnosisDiagnosis


Clinical


HistorHistorIs generally benign with a 5-year-survival rate ranging from 85-98%.

HistoryHistory

PhysicalPhysical

LaboratoryLaboratory

Associated with:



1. Cardiac Ischemia

2 Atherosclerosis


DiagnosisDiagnosis2. Atherosclerosis

3. Hypertrophic Cardiomyopathy

DiagnosisDiagnosis


Clinical


HistorHistor• Diagnosis

1. Angiography

HistoryHistory

PhysicalPhysical

LaboratoryLaboratoryg g p y

2. Others:



Doppler-flow catheterIVUSElectron beam CT


DiagnosisDiagnosisMultislice CTMagnetic Resonance TomographyTransthoracic doppler echocardiography

DiagnosisDiagnosis


Clinical


HistorHistor• Management

1 Beta blockers

HistoryHistory

PhysicalPhysical

LaboratoryLaboratory1. Beta blockers

2. Calcium channel blockers



3. No nitratesLeft Heart Left Heart


DiagnosisDiagnosis4. No stents

5. Surgical therapy

DiagnosisDiagnosis


Clinical

CONCLUSIONVignette

HistorHistor• This case illustrates the potential consequences of

intramyocardial bridging, including myocardial ischemia, as well as the clinical importance of suspecting this condition

HistoryHistory

PhysicalPhysical

LaboratoryLaboratorywhen a patient presents with intermittent episodes of severe chest pain that worsens with the administration of nitroglycerin.



• Although this clinical condition is rare and the treatment ismainly medical management, it is important to confirm thediagnosis with coronary angiography.


DiagnosisDiagnosis

• If the patient’s symptoms are refractory to medical management, or if they have a documented episode of a subsequent myocardialinfarction they may benefit from surgical intervention

DiagnosisDiagnosis


infarction, they may benefit from surgical intervention.

REFERENCES

1. Möhlenkamp S, Hort W, Ge J, Erbel R. Update on myocardial bridging. Circulation 2002; 106:2616.

2 Alegria JR Herrmann J Holmes DR Jr Lerman A Rihal CS Myocardial bridging Eur2. Alegria JR, Herrmann J, Holmes DR Jr, Lerman A, Rihal CS. Myocardial bridging. EurHeart J 2005; 26:1159.

3. Noble J, Bourassa MG, Petitclerc R, Dyrda I. Myocardial bridging and milking effect of the left anterior descending coronary artery: normal variant or obstruction? Am Jof the left anterior descending coronary artery: normal variant or obstruction? Am J Cardiol 1976; 37:993.

4. Faruqui AM, Maloy WC, Felner JM, Schlant RC, Logan WD, Symbas P. Symptomatic myocardial bridging of coronary artery Am J Cardiol 1978; 41:1305myocardial bridging of coronary artery. Am J Cardiol 1978; 41:1305.

5. Morales AR, Romanelli R, Boucek RJ. The mural left anterior descending coronary artery, strenuous exercise and sudden death. Circulation 1980; 62:230.

6 Ishikawa Y Akasaka Y Suzuki K Fujiwara M Ogawa T Yamazaki K Niino H Tanaka M

REFERENCES

6. Ishikawa Y, Akasaka Y, Suzuki K, Fujiwara M, Ogawa T, Yamazaki K, Niino H, Tanaka M, Ogata K, Morinaga S, Ebihara Y, Kawahara Y, Sugiura H, Takimoto T, Komatsu A, Shinagawa T, Taki K, Satoh H, Yamada K, Yanagida-lida M, Shimokawa R, Shimada K, Nishimura C, Ito K, Ishii T. Anatomic properties of myocardial bridge predisposing to myocardial infarction. Circulation 2009; 120:376.

7. Utuk O, Bilge A, Bayturan O, Tikiz H, Tavli T, Tezcan U. Thrombosis of a coronary artery related to the myocardial bridging. Heart Lung Circ 2010; 19:481.

8. Hostiuc S, Curca GC, Dermengiu D, Dermengiu S, Hostiuc M, Rusu MC. Morphological changes associated with hemodynamically significant myocardial bridges in sudden cardiac death. Thorac Cardiovasc Surg 2011; 59:393.

9 H L Nk l R W lf M K f PA M di l b id i i9. Husmann L, Nkoulou R, Wolfrum M, Kaufmann PA. Myocardial bridging causing infarction and ischaemia. Eur Heart J 2011; 32:790.

10. Hongo Y, Tada H, Ito K, Yasumura Y, Miyatake K, Yamagishi M. Augmentation of vessel squeezing at coronary myocardial bridge by nitroglycerin: study by quantitative coronarysqueezing at coronary-myocardial bridge by nitroglycerin: study by quantitative coronary angiography and intravascular ultrasound. Am Heart J 1999; 138:345.

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ACP FLORIDA CHAPTER CLINICAL VIGNETTE ORAL