COTW 8/20: An 82yo M presents with chest pain...

An 82 man with a past medical history of HTN, HLD presents to the Emergency Department with chest pain. He reports several months of exertional chest pain that improves with rest but for the past two days he has had persistent chest pressure. 

An EKG is notable for new atrial fibrillation and ST depressions in leads V5-6 without ST elevations. 

Bedside echocardiography was performed:

Parasternal short axis view

Apical four chamber view

The findings are subtle, but the proximal septum appears relatively hypokinetic when compared with the cardiac apex and the visualized portion of the left ventricular free wall. Notice how on the parasternal short axis view the anterior and posterior walls move inwards more than the septal wall. On the apical four chamber view, notice how the septum does not move as vigorously as the LV free wall. There is some movement of the heart with the patient’s respirations and he is in atrial fibrillation which makes interpretation more difficult, but compare them with the normal echo findings below:

Parasternal short axis with concentric contraction of the left ventricle

The patient had an elevated troponin and was admitted for medical management of his NSTEMI. He was taken taken for cardiac catheterization the day after hospital admission and found to have diffuse moderate atherosclerotic disease with severe stenosis of the posterior descending artery (PDA).

See below:

We can see that the more posterior portion of the septum is supplied by branches of the RCA which includes the PDA. Proximally, the posterior septum is supplied by the PDA while the more distal portions and the apex are supplied by the LAD. The severe stenosis diagnosed on the patient’s cardiac catheterization is therefore consistent with the wall motion abnormality seen on his ultrasound.

The patient did not receive coronary artery stenting during his catheterization and cardiology recommended medical management of his disease. His troponin peaked at 4.5.