Left Unilateral Pulmonary Edema Complicating Acute Myocardial Infarction: A Rare Presentation.

Left Unilateral Pulmonary Edema Complicating Acute Myocardial Infarction: A Rare Presentation.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 105A
Bengaluru Jayanna M, Schima S, Aboeta A

SESSION TYPE: Cardiovascular Student/Resident Case Report Posters IPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM – 02:30 PMINTRODUCTION: Unilateral pulmonary edema (UPE) is a rare complication of acute ischemic severe mitral regurgitation (MR) that almost always appear as a right focal lung opacity. We present a case of pulmonary edema limited to the left hemithorax associated with acute myocardial infarction (MI).CASE PRESENTATION: A 68-year-old woman, with known coronary artery disease, was admitted with worsening recurrent chest pain and mild dyspnea of 2 weeks duration. On examination, she was hypoxic with 80% oxygen saturation on room air which improved with lying on her right side. Blood pressure was 100/65, pulse 60/min, respiratory rate 20/min. Auscultation revealed crackles in the lower two thirds of the left lung and an apical soft pansystolic murmur. EKG showed new ST segment depression in leads V2-V5. Chest X-ray (CXR) showed left hemithorax opacification indicating UPE. Troponin level was elevated. The diagnosis of non-ST elevation MI was made and the patient was treated with Heparin, nitroglycerin, clopidogrel and asprin,in addition to IV furosemide and CPAP. Transthoracic echocardiography showed new severe eccentric MR with hypokinesis of the lateral and posterior walls and an ejection fraction of 45-50%. Urgent cardiac catheterization showed acute totally occluded left circumflex artery which was successfully opened and stent placed.The patient gradually improved clinically after the procedure with a good response to diuretics. A follow-up CXR showed complete resolution of the pulmonary edema.DISCUSSION: UPE is a rare, frequently misdiagnosed radiologic and clinical condition with a variety of mechanisms, both cardiac and non-cardiac. One etiology is ischemic MR. Right-sided pulmonary edema is a rare complication in various case reports with the frequent use of transesophageal echocardiography as a tool to demonstrate eccentric MR jet targeting the ostia of one of the right pulmonary veins, with reversal of flow in the veins resulting in focal pulmonary edema. Left-sided pulmonary edema is even less frequently seen possibly due to the direction of the regurgitant stream and the superior left lung lymphatic drainage. The prevalence of right pulmonary veins sharing common ostia is only 0.5%, compared to 8-14% for the left pulmonary veins. This might be a possible explanation of the focal nature of right UPE versus the UPE involving the entire left hemithorax as seen in our case.CONCLUSIONS: This case illustrates the possibility of acute ischemic MR being complicated by UPE involving the left hemithorax. Although it is extremely rare, it should be considered in the differential diagnosis in an appropriate clinical setting. Prompt diagnosis and aggressive treatment is necessary as both acute ischemic MR and UPE are independently associated with increased mortality.1) Circulation. 2010 Sep 14;122(11):1109-15. Epub 2010 Aug 30. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema.DISCLOSURE: The following authors have nothing to disclose: Manju Bengaluru Jayanna, Susan Schima, Ahmed AboetaNo Product/Research Disclosure InformationCreighton University Medical Center, Omaha, NE. HubMed – depression

Point-of-Care Prognosis for Common Musculoskeletal Pain in Older Adults.

JAMA Intern Med. 2013 May 13; 1-7
Mallen CD, Thomas E, Belcher J, Rathod T, Croft P, Peat G

IMPORTANCE Many site-specific, multivariable risk models for predicting the outcome of musculoskeletal pain problems have been published. The overlapping content in these models suggests a common set of generic indicators suitable for use in primary care. OBJECTIVE To investigate whether a brief set of generic prognostic indicators can predict the outcome of musculoskeletal pain in older patients presenting to general practitioners. DESIGN, SETTING, AND PARTICIPANTS A prospective observational cohort study conducted from September 1, 2006, through March 31, 2007, of consecutive patients 50 years or older presenting with noninflammatory musculoskeletal pain to 1 of the 5 participating general practices in the United Kingdom. MAIN OUTCOME MEASURES During consultation, the treating physician assessed and recorded 5 brief generic items (duration of present pain episode, current pain intensity, pain interference with daily activities, presence of multiple-site pain, and ultrashort depression screen) and recorded their overall prognostic judgment. The primary outcome was patient-rated improvement, which was measured 6 months after consultation and cross-validated with repeated measures up to 3 years. RESULTS A total of 194 (48.1%) of 403 participants were classified as having an unfavorable outcome at 6 months. Inclusion of 3 generic prognostic indicators (duration of present pain episode, pain interference with daily activities, and presence of multiple-site pain) in the prognostic model improved on reliance on physicians’ prognostic judgment alone (C statistic = 0.72 vs 0.62; net reclassification index = 0.136; proportion correctly classified = 69%). The improvement in prognostic accuracy was attributable to correcting physicians’ tendency toward overoptimistic expectations of outcome. CONCLUSIONS AND RELEVANCE Three easy-to-obtain pieces of information followed by systematic recording of the general practitioners’ prognostic judgment provide a simple generic assessment of prognosis at point of care in older persons presenting with musculoskeletal problems to primary care practices in the United Kingdom. Such an assessment offers a common foundation for investigating the usefulness of prognostic stratification for guiding management in the consultation across a range of common painful conditions. HubMed – depression

Nonatherosclerotic Coronary Angina: Lung Steals Blood From the Heart.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 45A
Boppana VS, Nandavaram S, Jogani S, Carhart R

SESSION TYPE: Surgery Student/Resident Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM – 02:30 PMINTRODUCTION: Angina occurs when myocardial oxygen demand exceeds oxygen supply; the clinical manifestation is often chest discomfort. Several non-atherosclerotic conditions have been studied and reported in literature that cause angina in rarity.CASE PRESENTATION: A 40 year old Chinese healthy male presented to the emergency department with chest pain described as heavy, retrosternal, non-radiating, constant for 30 minutes associated with dizziness, nausea and palpitations which started while lifting a weight of 40 pounds. It relieved gradually with rest. His physical activity was limited due to the chest discomfort (CCS Class II angina). He had a smoking history of 10 packs per day without alcohol or illicit substance use and an insignificant family history. His physical exam was positive for grade II/VI continuous murmur at the left sternal border, with clear lungs and normal jugular venous pressure. His exercise stress test which was terminated at 7 minutes as he developed dizziness, ST segment depression in the lateral leads along with non-sustained ventricular tachycardia and a transient left bundle branch block. Cardiac catheterization showed insignificant coronary artery disease but revealed a fistula leading from the Left anterior descending (LAD) to the main pulmonary artery. This was confirmed by Coronary CT angiogram coursing within the epicardial fat along the lateral aspect of the pulmonary outflow tract. An attempt to coil the fistula via the pulmonary circulation was unsuccessful. Robotic arm assisted ligation in the operating room showed a 1-cm long feeding vessel coming off the LAD with only one visualized branch, which was isolated and ligated close to the LAD. TEE was used to confirm the presence and absence of flow. This resulted in patient recovery without any complications.DISCUSSION: A coronary artery fistula (CAF) is an abnormal communication between an epicardial coronary artery and a cardiac chamber or a major vessel. They may present at any age and are mostly congenital. Whether or not a patient will develop symptoms depends on the degree of volume overload and severity of the left to right shunt. Coronary angiography still remains the gold standard for diagnosis. Surgical ligation and transcatheter embolization are known treatment options for CAF.CONCLUSIONS: Our patient presented with symptoms of stable angina, further unmasked during exercise stress testing. His symptoms are explained by the “steal” phenomenon where coronary blood flow is shunted to the pulmonary artery at the expense of myocardium, resulting angina. Symptoms abated after successful ligation of the fistula using a robotic arm.1) Heart failure with transient left bundle branch block in the setting of left coronary fistula. Juraschek SP, Kovell LC, Childers RE, Chow GV, Hirsch GA. Source Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Baltimore, MD 21224, USADISCLOSURE: The following authors have nothing to disclose: V Subbarao Boppana, Sravanthi Nandavaram, Sidharth Jogani, Robert CarhartNo Product/Research Disclosure InformationSuny Upstate Medical Center, Syracuse, NY. HubMed – depression