Summary 11

Madam KAA, an 81 year-old all-time housewife with previous diagnoses of left ventricular failure under cardiology follow-up in Hospital Sultanah Aminah, Johor Bahru, dyslipidaemia, hypertension on medications and type II diabetes mellitus on diet modification presented with sudden onset of excruciating central chest pain, radiating to the back while at rest for ten hours prior to the hospital admission. The chest pain was associated with shortness of breath. She did not have profuse sweating, nausea or vomiting. She took two tablets of sublingual glyceryl trinitrate but the pain was not relieved.

Question: Why do you think she has shortness of breath? Why is the pain of myocardial infarction not relieved by sublingual GTN?

Physical examination revealed her pulse rate was 96 beats per minute, regular, strong volume, and normal in character. She was not tachypneic with respiratory rate of 22 breaths per minute. She was haemodynamically stable with blood pressure 166/98mmHg and temperature 370c. Her body mass index was 22.5kg/m2. Her waist circumference was 78cm. There was conjunctival pallor. The apex beat was shifted at the 6th intercostal space 2cm lateral from the left midclavicular line. Besides orthopnoea, there were no other signs and symptoms for heart failure.

Question: What is the significance of the position of her apex beat?

Her electrocardiogram showed sinus rhythm with ST depression more than 2mm at leads aVL and V6, deep Q wave at leads II, aVF, V1 and V2, and left ventricular hypertrophy.

Question: Why does she have LVH? How will you interpret deep Q waves in Lead V1?

Her cardiac enzymes were raised with Troponin I 0.65ng/ml. She was managed as acute non-ST elevation myocardial infarction. She completed three days of subcutaneous fondaparinux 2.5mg and was started on clopidogrel besides to continue her pre-existing medications which were aspirin, isosorbide-5-mononitrate, furosemide, potassium chloride, perindopril, and atorvastatin.

Question: What potential problem do you anticipate with the potassium chloride prescribed for her? Why is it being prescribed?

Her stay in the ward was uneventful. She was discharged well with the medications taken in the ward besides fondaparinux. She was to come back to be reviewed in the outpatient clinic with blood investigations result in three months’ time. She was to continue her cardiology follow-up in Hospital Sultanah Aminah, Johor Bahru. Echocardiography was not done and angiogram was not planned. She and her family members understood about her condition and were not keen for any surgical intervention in view of her old age and the complications of surgery.

Question: In view of her diabetes, what can you say about the severity and / or extent of her coronary artery disease?

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