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Physician / Resident Forums [ MD / DO ]
Anesthesiology
Positive stress test for non cardiac surgery
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<blockquote data-quote="vector2" data-source="post: 22237942" data-attributes="member: 129287"><p>I just got done covering a couple days in the MICU. We take a HD2 admit from the floor with afib RVR hx of pAF, DM, HTN supposedly non-obstructive CAD. He had been doing fine on the floor but then started getting progressive dyspneic with poor response of the RVR to dilt. We do not have his outside records but he’s not been taking his metoprolol but he has been taking his eliquis. Doesn’t appear to have a cardiologist. Does not take ASA or statin. He’s in pulmonary edema, LVEF is down to 25% when we bedside echo him. No hx of ischemic CM. May be tachycardia mediated. Diaphoretic as hell. He’s complaining of chest pain (mostly sounds like palpitations) but maintaining his bp fine. We stop the dilt, amio load, lasix 80 IV, bipap. Stat ekg and trop are stone cold negative except for afib. Yesterday’s EKG and trop were also negative. We give him ASA 81 and high dose atorva given his possible CAD history and risk factors. Starts getting symptomatic relief, chilling in bed.</p><p></p><p>A few hours later he decides to get up without calling the nurse. Syncopizes. We put him back in bed but he’s now persistently hypotensive and requiring high dose levo to maintain MAP 65. Chest pain back. Stat EKG and trop. EKG with obvious anterolateral STEMI. Goes to cathlab. Trop comes back >80. They find a mid-LAD plaque rupture, diffuse RCA and LCx.</p><p></p><p>The moral of the story is that this guy has severe 3v disease and has been undergoing a 36-48h stress test without even leaking any troponin. A large, large percentage of acute MIs are due to plaque rupture, so not having someone on medication which helps to prevent plaque rupture (and mitigates the rupture if it does happen) before an extremely inflammatory event doesn’t seem right.</p></blockquote><p></p>
[QUOTE="vector2, post: 22237942, member: 129287"] I just got done covering a couple days in the MICU. We take a HD2 admit from the floor with afib RVR hx of pAF, DM, HTN supposedly non-obstructive CAD. He had been doing fine on the floor but then started getting progressive dyspneic with poor response of the RVR to dilt. We do not have his outside records but he’s not been taking his metoprolol but he has been taking his eliquis. Doesn’t appear to have a cardiologist. Does not take ASA or statin. He’s in pulmonary edema, LVEF is down to 25% when we bedside echo him. No hx of ischemic CM. May be tachycardia mediated. Diaphoretic as hell. He’s complaining of chest pain (mostly sounds like palpitations) but maintaining his bp fine. We stop the dilt, amio load, lasix 80 IV, bipap. Stat ekg and trop are stone cold negative except for afib. Yesterday’s EKG and trop were also negative. We give him ASA 81 and high dose atorva given his possible CAD history and risk factors. Starts getting symptomatic relief, chilling in bed. A few hours later he decides to get up without calling the nurse. Syncopizes. We put him back in bed but he’s now persistently hypotensive and requiring high dose levo to maintain MAP 65. Chest pain back. Stat EKG and trop. EKG with obvious anterolateral STEMI. Goes to cathlab. Trop comes back >80. They find a mid-LAD plaque rupture, diffuse RCA and LCx. The moral of the story is that this guy has severe 3v disease and has been undergoing a 36-48h stress test without even leaking any troponin. A large, large percentage of acute MIs are due to plaque rupture, so not having someone on medication which helps to prevent plaque rupture (and mitigates the rupture if it does happen) before an extremely inflammatory event doesn’t seem right. [/QUOTE]
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Physician / Resident Forums [ MD / DO ]
Anesthesiology
Positive stress test for non cardiac surgery