Symptoms to Diagnosis

An unexpected turn: A 71-year-old man with myocardial infarction

Smitha Ganeshan, MD, MBA, Benjamin Kelemen, MD, Gurpreet Dhaliwal, MD and Lucas Zier, MD, MS
Cleveland Clinic Journal of Medicine July 2022, 89 (7) 401-407; DOI: https://doi.org/10.3949/ccjm.89a.21030

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    The patient’s electrocardiogram in the emergency department showed ST-segment elevation (arrows) in leads II, III, and aVF, and ST-segment depressions (triangles) in V1, V2,, V3,, and aVL.

  • Figure 2
    Figure 2

    Coronary angiography revealed a left dominant circulation with the posterior descending artery and posterolateral branches arising from the left circumflex artery. A large filling defect was visualized in the left dominant circumflex artery as well as distal cutoffs in multiple obtuse marginal branches.

  • Figure 3
    Figure 3

    On repeat electrocardiography 48 hours after presentation, the ST-segment elevations in leads II, III, and aVF were still present. The ST-segment depressions in aVL and V1-V3 had resolved, and new ST-segment elevations were present in V4 and V5 (arrows).

  • Figure 4
    Figure 4

    Transesophageal echocardiography on hospital day 3 showed an 8-mm vegetation on the aortic valve (arrow).

Tables

  • TABLE 1

    Types of shock

    MechanismPulmonary capillary wedge pressureCardiac outputSystemic vascular resistanceTreatment
    DistributiveLowNormal or highLowPressors
    Intravenous fluids
    Etiology-specific therapies (eg, antibiotics, epinephrine)
    CardiogenicHighLowHighInotropes
    Mechanical circulatory support
    HypovolemicLowNormal or lowNormal or highIntravenous fluids
    Etiology-specific therapies (eg, blood transfusion)
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