Kudos to Dr. Beth Hanson.
One of our recently graduated fourth-year residents, who will be an attending in Colorado, went above and beyond the call of duty just a few weeks ago. Dr. Aleksandr Gleyzer nominated Dr. Hanson for acknowledgment.
It was a relatively busy CCT shift when Dr. Hanson got a 59-year-old with a history of CAD s/p CABG 10 years ago who presented with three days of progressively worsening shortness of breath. Three hours ago the patient noted dyspnea at rest. Vital signs were HR 69/min, BP of 90/50 mm Hg, RR 25/min, T 98 F, SpO2 88% RA. The exam demonstrated bibasilar rales, somewhat cool distal extremities, and normal mental status. Dr. Hanson quickly spotted this ECG:
Dr. Hanson immediately identified ST-elevation in aVR and diffuse ST-depressions. She was concerned about a left main or proximal LAD occlusion and immediately called a code H. (You can read more about elevation in aVR here.) Labs showed a pH of 7.1, a troponin of 15, and a lactate of 16. Dr. Hanson quickly decided to intubate the patient. She masterfully guided one of our junior residents through a smooth intubation. Supervising a procedure requires much more skill than performing the procedure yourself.
At our main institution, we have to transfer patients to our secondary site across the street for PCI. Before the transfer, Dr. Hanson made sure to load the patient with ASA, clopidogrel, and heparin, as well as adequate analgesia for the intubation. Dr. Hanson even rode with the patient on the ambulance to the cath lab to ensure timely intervention!
The angiogram revealed severe triple vessel disease with occlusions of the previous grafts, most notably at the distal anastomosis sites. The cardiology team started pressors and placed an intra-aortic balloon pump. The patient was deemed a poor candidate for revascularization and was then admitted to the CCU and managed medically. The hospitalization was complicated by AKI.
After managing cardiogenic shock, the patient had a relatively uneventful course. The team quickly noted that the patient would likely benefit from subacute rehab, however, due to the patient’s insurance, she was not eligible. The family, the team, and the patient together were able to decide on a safe discharge home with home-care services.
Noah Berland
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2 Comments
Mo · July 23, 2019 at 8:48 pm
Would you load with plavix with a potential left main? Who knows if they need CABG?
Noah Berland · August 20, 2019 at 12:00 pm
Hi Mo! Great Comment. This is a heavily debated topic. Here is a great position statement from the Canadian Cardiovascular Society: Dual antiplatelet therapy in patients requiring urgent coronary artery bypass grafting surgery: A position statement of the Canadian Cardiovascular Society https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807829/
Their number 1 recommendation: All ACS patients should be considered for dual antiplatelet therapy with ASA and clopidogrel at the earliest opportunity, despite the possibility of a need for urgent CABG.
It is a very tough balance between the anti-ischemic benefits of of clopidogrel and its increase in bleeding risk. Some patient also refuse CABG and end up undergoing a staged PCI. Further this patient has already developed ischemic heart failure with low flow, and is at very high risk of a recurrent ischemic event.