CASE 1
PATIENT'S HISTORY:
The patient was 76-year-old white male with chronic renal failure and long-standing hypertension who was admitted for L2-L5 posterior lumbar fusion. The patient experienced a period of intraoperative hypotension that extended to the postoperative period and required temporary treatment with pressor agents. Several hours postoperatively routine ECG showed T-wave changes in lateral leads, and subsequently a new left bundle branch block (LBBB). There was no previous ECG for comparison. At that time the patient did not have any chest pain, shortness of breath or any other symptoms. His physical exam was unremarkable, except for a new third heart sound. There was no history of prior cardiac events. The results of the first set of cardiac enzymes (CK, CK-MB, troponin I) was consistent with a new myocardial infarction (MI).
Past medical history was also significant for hyperlipidemia, gout, right leg deep venous thrombosis (DVT), multiple back surgeries, bilateral knee replacements and cataract removals.
Medications included allopurinol, trazodone, pravachol, aspirin, verapamil and lisinopril. The patient did not consume alcohol and did not smoke. His father died at the age of 60 of myocardial infarction.
The patient remained asymptomatic, and his later ECGs showed normal sinus rhythm, with persistent LBBB (Table 1). Repeated sets of cardiac enzymes confirmed the presence of MI (Table 2). Transthoracic echocardiogram showed left ventricular hypertrophy and global hypokinesis. The medical regimen was readjusted and patient was transferred for cardiac rehabilitation.
ECG FINDINGS:
| Day | Time | Results |
|---|---|---|
| Day 1 | 2:55 PM | ST-T wave abnormality compatible with lateral ischemia |
| Day 1 | 9:00 PM | LBBB and sinus tachycardia |
| Day 2 | 5:39 AM | Nonspecific intraventricular conduction delay and T wave abnormality compatible with lateral ischemia |
| Day 2 | 4:00 PM | Septal infarct pattern, age undetermined. ST abnormality compatible with lateral subendocardial injury or infarction. ST abnormality is more marked than T wave abnormality previously, and ST is new. |
| Day 3 | 7:00 AM | Normal sinus rhythm. Left ventricular conduction defect. As compared to day 2 supraventricular tachycardia is no longer present and QRS duration has decreased. |
| Day 7 | 7:00 AM | Normal sinus rhythm with premature ectopic complexes. LBBB with associated repolarization abnormality. As compared to day 3, no significant change |
| DAY | TIME | T CPK (normal 0-200 IU/L) |
MB CPK (normal <7 IU/L) |
RI (normal <3) |
TROPONIN I (normal < 1.5 ng/mL) |
|---|---|---|---|---|---|
| Day 1 | 00:15AM | 1494 | 33.9 | 2.3 | 66.6 |
| Day 1 | 10:40 AM | 1544 | 54.2 | 3.5 | 83.1 |
| Day 1 | 05:24 PM | 2286 | 64.5 | 2.8 | 125.7 |
| Day 2 | 11:40 PM | 2536 | 65.4 | 2.6 | 141.7 |
