SHA24/060001

Interactive Case Presentation Dr. Raed Alkutshan, MD

Mr. Y.M ď Ž

Mr. Y is a 54 year-old gentleman with the following history: - Insulin requiring type DM - Hyperlipidaemia - HTN - IHD - PVD - Chronic renal dysfunction

Cause For Admission

ď Ž Left diabetic foot and wet gangrene

for management.

PMH 

Long standing DM, > 20 y on insulin.



Long standing HTN, 25 years on Adalat LA 60 mg.



Dyslipidemia about 20 years on Zocor 20 mg



Diabetic nephropathy CKD stage III to IV “ eGFR is 36 ml/min” diabetic nephropathy, on conservative management.

Past history of PAD



Established PVD 4 y ago, S/P “below knee amputation” of the right leg in 2009, replaced by prosthetic limb.

Past Cardiac History 



Established IHD, CATH at 2000: 

LAD: 50% stenosis proximally, 40% stenosis at bifurcation level of D1, distal lesion 80%



D1: 50% proximal stenosis



LCX: very small and non dominant with sever proximal disease



RCA: large and dominant, 70% proximal lesion, 60% distal lesion



PDA: severely diseased and the disease was diffused in nature

Deemed For medical therapy

Planned for popliteal angioplasty Given his baseline CKD nephrology consulted ď Ž Advised to: 1. Hydrate with 0.9NS, 40cc/hr for 24hr to 2. N-acetyl cysteine 1200gm BID for 3 days 3. Hold lasix ď Ž

The procedure ď Ž

Patient underwent left leg angioplasty with 3 stents of the left popliteal artery and extensive debridement under local anesthesia of the left leg

Cardiology consulted!! ď Ž

Day #1 post angioplasty at 1 AM, patient start to complain of S.O.B at rest and chest discomfort

ď Ž

Cardiology were consulted for an opinion and management

Further History ď Ž

Functional Capacity is Moderate: Able to walk about 3 Km daily

ď Ž

Denies any chest pain or S.O.B before hospitalization either at rest or usual daily activity

On examination 

Patient looks uncomfortable



BP 130/80 mmHg



HR is 95/m regular, good volume



His exam is notable for mildly elevated jugular venous pulse (JVP), bilateral decrease in breath sounds with crackles up to mid zone. A normal S1, S2 with an S3 gallop, and a grade II pan systolic murmur in the mitral area radiating to axilla.

Pre-procedure ECG

ECG during symptoms

Chest X-Ray baseline

Chest X-Ray during event

ECHO

At Time Of Admission

Baseline Laboratory Data At Time Of Admission HEMATOLOGY

Laboratory Data At Time Of Admission BLOOD CHEMISTRY

1 st result of Cardiac Markers during event

2 nd result of Cardiac Marker

Troponin trend hrs 48

Within 1hr

2hrs

What is your impression?

A. B. C. D.

ACS Not an ACS Acute heart failure (decompensated) Fluid over load with background CKD

Cardiology service actions  ACS protocol was started in

combination with anti failure treatment  Medical Rx for now  MPI to risk stratify

2 days after 

Patient still symptomatic, complaining of dyspnea with walking to bath room (NYHA III)



Clinically out of decompensating HF



Patient medical treatment is almost maximized.

Result of Cardiac Marker

Laboratory Data HEMATOLOGY

Laboratory Data BLOOD CHEMISTRY

Cardiology decided the following 

   

Thoroughly treat his acute heart failure medically Investigate cause for anemia Transfuse 2 units of PRBC Schedule for cardiac Cath Ask nephrology to prepare patient for Cath

What is his CV death based on clinical indices ? <1% B. 1-5% C. 5.1-10% D. > 10.1% A.

Which of the following statements is TRUE concerning (CKD) and cardiovascular disease?

A. Patients with CKD are at increased risk of bleeding but decreased risk of thrombotic events when compared with normal individuals B. The outcomes of patients with CKD and ACS are similar to those with ACS and normal renal function C. Renal dysfunction is the most significant independent predictor of inhospital mortality D. Patients with CKD who present to the hospital with chest pain comprise a relatively low-risk group of ACS, with a cardiac event rate of <5% at 30 days E. Uremia is associated with enhanced platelet aggregation

GRACE score= 164 In-hospital death= 5.4%

Patient scheduled for coronary angiogram You estimate his percentage risk of significant CI-AKI to be which of the following?

A. <1% B. 5% C. 10% D. 13% E. 26%

Which of the following is recommended to reduce the risk of contrast-induced nephropathy ?

A.

Pre-med with N-acetylcysteine Nacetylcysteine

B.

Hydrate before procedure, keep contrast volume low.

C.

Pre-med with fenoldapam

D.

Pre-med with IV sodium bicarbonate

E.

Dialyse patient post procedure to prevent