Nuke Cases

Nuclear/Cath Correlation Conference David M. Whitaker, MD University of South Florida Department of Cardiology

Case #1 55 yo man seen in clinic for chest pain Left sided Sharp Both at rest and with activity – 5/10 severity Has dyspnea with mild-mod exeretion No alleviating factors/meds

Case #1 PMH Diabetes – poorly controlled HTN Hyperlipidemia Seizures Depression

Social Divorced, 5 kids, lives with his mother. On disability for seizures. Prior 6 pack per day – quit one year ago. Non-smoker. Cocaine in early 1980’s, none since

Case #1 Medications Aspirin 325mg Simvastatin 40mg HCTZ 25mg Metoprolol 50mg bid Insulin, metformin, gabapentin, etodolac carbamazapine

Case # 1 Examination BP 148/78, HR 87, T 99.1, RR 18, BMI 37 Obese man in no distress Normal S1S2, no m/r/g, +/- jvd Soft bibasilar crackles Soft obese abdomen 1+ pitting leg edema with palpable pulses

Case #1 LABS A1c – 11.3 Hgb 14 Na 136, co2 34, bun 20, creat 1.2, gluc 212 Alk phos 148, normal ast/alt Chol 208, tri 101, hdl 60, ldl 128

EKG

Case #1 Adenosine Stress Test

Case #1 Adenosine Stress Test Mild to moderate potential ischemia of the lateral and inferolateral walls apex  base EF 46-48%

Case #1 Heart Cath

Case #1 Heart Cath Right Dominant Left Main – okay LAD – 99% discrete lesion Circ – mid 100% RCA – proximal 35%, distal Lum.Irreg 30% Collateral – Ramus  Marginal EF – 55% LV 152/3, 18

Case #1 Cath Conference  try PCI PCI to LAD (Xience) 2.75 x 18mm PCI to Circ (Xience) 2.75 x 28mm

Case #2 61 yo man with no prior cardiac history referred from anesthesia for CRA due to abnormal EKG Planned to undergo FESS with brain lab & polypectomy under general anesthesia Denied chest pain, orthopnea, PND etc…

Case #2 PMH Recurrent DLBC lymphoma s/p chemos COPD/Asthma Hyperlipidemia

Social Married, works as a security officer Long time smoker, occas alcohol

Case #2 Medications Simvastatin 20mg Paroxetine Oxycodone Albuterol, mometasone, formoterol, albuterol xanax

Case #2 Examination 111/80, 74, 98.1, 16, No jvd, normal carotids Clear lungs Normal S1S2, pmi No edema, normal pulses

207 lbs

Case #2 Labs Na 141, co2 30, bun 14, creat 1.0, gluc 185 Wbc 9, hgb 14.6, plt 225 Chol 172, tri 175, hdl 62, ldl 75

EKG

Case #2 AST recommended  Dobutamine Echo

Case #2 Dobutamine Nuclear Markedly dilated LV Inferior wall ischemia of varying severity from apex  base EF 30% with global hypo

Case #2 Echo EF 40% Severe hypo basal inferoseptal, basal inferior Remaining walls mod hypo Biatrial dilatation Mild MR, trace-mild TR RVSP 50 mmHg

Case #2 Cath

Case #2 Cath Normal coronaries Normal systemic pressure LVEDP 26 PCWP 25 PAS/PAD 54/21 RA 8 CO 4.8, CI 2.28 (both by Fick) EF 30% with global hypo

Case #3 62 yo man seen for CRA for inguinal hernia repair as EKG abnormal No known prior CAD documented by cath per his memory Sleeps on 2 pillows, no chest pain COPD at baseline with irregular use of inhaler meds

Case #3 PMH CVA HTN Hyperlipidemia GERD BPH

Social Single, disabled 0.5 – 1 ppd long time, occas alcohol

Case #3 Meds Simvastatin 20mg Lisinopril 5mg Metoprolol 12.5mg bid Aspirin 81mg Combivent, formoterol baclofen

Case #3 • Examination – 125/72, 60, 99.2, 16, 155 lbs No jvd, no bruits Regular S1S2, +S4 – Lungs are clear Faint left femoral Large right inguinal hernia – Pedal pulses palpable, no edema

EKG

Case #3 • AST

Case #3 • AST Moderately severe ischemia in apex and apical 1/3rd of anterior, anteroseptal, inferoseptal walls – Post-stress stunning evident TID present EF 54-60%

Case #3 • Echo – EF 60% Normal wall motion, normal LV thickness Trace-mild MR

Case #3 • Cath

Case #3 • Cath – Severely calcified LAD with ostial 80%, proximal 95%, mid 100% Distal LAD fills via collateral Mild circumflex disease – Diffuse 70% mid and distal RCA 80% ostial PDA

Case #4 • 70 yo man with known CAD/PCI in January • Admitted with chest pain/tightness starts on the right lower chest and radiates to the left chest and abdomen. Is associated with SOB. Lasts for 15-30 minutes Came to hospital when realized his HR also was elevated

Case #4 • PMH – CAD s/p PCI in January HTN PVD – Hyperlipidemia DM2 Sickle Trait • Social Married, healthy son, retired 20 pack yr smoker, quit 30 yrs ago, no etoh

Case #4 • Meds – Aspirin Plavix Lisinopril 20mg – Isosorbide mononitrate 30mg Coreg 25mg bid Lasix 40mg – Insulin 70/30 Simvastatin 80mg

Case #4 • Examination – 117/73, 81, 97.9, 18, 243 lbs No jvd, no bruits Irreg irreg, normal S1S2 – Clear lungs Obese but normal abd +3 pitting leg edema – Normal distal pulses bilaterally

Case #4 • Labs – Wbc 10 Hgb 15 Plt 233 – Na 137, co2 27, bun 35, creat 1.8, gluc 153 Bnp 461, trop 1.197, ckmb 12.38 Chol 149, tri 101, hdl 42, ldl 87

EKG

Case #4 • AST

Case #4 • AST Potential ischemia in the apex and apical 1/3rd of the lateral wall EF 59-61% Slightly greater potential ischemia than study in March

Case #4 • Cath

Case #4 • Cath – Left main okay LAD – patent prior mid stent Circ – minimal luminal irreg RCA – minimal luminal irreg EF 60%, normal wall motion