Under Pressure: Ambulatory Blood Pressure Control

Smart AIM: Improve hypertension control with the following goal: Within three months 60% of patients with hypertension will have a blood pressure less than 140/90 during their most recent office visit.https://jdc.jefferson.edu/patientsafetyposters/1029/thumbnail.jp

An Expanding Heart: A Case for a Left Ventricular Rupture

Introduction: A ventricular aneurysm was once a common complication of a myocardial infarction (MI), seen in up to 35 percent of coronary occlusion with transmural tissue damage.1 The advent of percutaneous coronary intervention (PCI) and thrombolytic therapy, which produced effective arterial patency, had a direct correlation with the reduction in the number of myocardial infarctions complicated by aneurysm, with the current incidence at 15 percent.2 Aneurysmal formation and rupture is a life-threatening complication of an MI and clinicians should be aware of its signs and management. We present a case of ST elevation MI (STEMI) complicated by left ventricular aneurysmal formation and rupture post PCI. Case Presentation: A 75-year-old male with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, benign prostatic hypertrophy, and recent STEMI status post bare metal stent to the distal right coronary artery (RCA) re-presented five days post MI with substernal chest and back pain. His exam was significant for mild distress and a friction rub. Electrocardiogram (EKG) showed 3-5 mm inferior and lateral ST elevations. Troponin T was 1.29. Emergent left heart catheterization showed no change from previous intervention. Transthoracic echocardiography (TTE) at this time was unchanged from previous hospitalization, consistent with left ventricular dysfunction, akinesis of several walls, and unchanged left ventricular aneurysm without evidence of rupture or pericardial effusion. Given the continued chest pain, elevated troponin, and new pericardial friction rub, cardiac CT was performed to evaluate the myocardium which showed a markedly thinned aneurysmal wall without signs of rupture. Although aneurysmorrhaphy was considered, the patient was deemed a poor surgical candidate due to age and poor functional capacity