CVR Pathology

Patient Presentation

• Patient: Barry, a 55-year-old male plumber, former semi-professional footballer for Blackburn Rovers.
• Smoker (pipe).
• Drinks socially.
• Presenting complaint: chest pain.

Examination Findings

• Chest clear to palpation.
• Heart sounds (HS) normal.
• Abdomen soft, non-tender (SNT).
• No pedal edema.
• Right leg more swollen than left, attributed to a football accident 30 years prior, with a metal plate present

Investigations

• ECG: sinus rhythm, T-wave inversion.
• Chest X-ray: normal.
• Bloods (6 hours): Troponin I elevated at 2049 ng/L (normal range 0-58 ng/L).
• Bloods (6 hours later): Troponin I significantly elevated at 2846 ng/L.

Troponin Information

• Protein in cardiac and skeletal muscle.
• Involved in muscle contraction, responsive to calcium.
• Released after cardiac injury.
• Elevated Troponin levels indicate potential myocardial damage.

Echocardiogram Findings

• Mild to moderate aortic stenosis with mild regurgitation.
• Normal right ventricular (RV) size and function.
• Normal left ventricle structure, impaired function (global hypokinesia, estimated ejection fraction (EF) 25%).
• Dilated bi-atrial size and function.
• Mild to moderate mitral regurgitation.

Differential Diagnosis

• Acute coronary syndrome (ACS).
• Aortic dissection.
• Myocarditis.

ACS Treatment

• Antiplatelet therapy (DAPT, Fondaparinux)
• ACE inhibitor
• Beta-blocker
• Statin

Possible Management

• Furosemide (diuretic) acutely.
• Uptitrating beta-blocker dose (possibly digoxin).
• ACE inhibitor.
• Potassium-sparing diuretic.
• Coronary revascularization therapy (CRT).

Further Presentation (2 days later)

• Shortness of breath (SOB).
• Difficulty lying flat.
• Leg swelling.

Further Investigations and Results (2 days later)

• ECG: ST depression.
• Chest X-ray: Signs of congestion and pulmonary edema.
• Further Blood test: Further high troponin (1633 ng/L)

Diagnosis

• Possible new Myocardial Infarction (MI)
• Hospital-acquired pneumonia (HAP).
• Aspiration pneumonia.
• COVID.
• Pulmonary edema, secondary to fast Atrial Fibrillation (AF).

Management (2 days later)

• Further investigation and treatment as required, based upon the elevated results of investigations and symptoms.

Discharged

• Follow up with cardiology.
• Community heart failure team.
• Fluid restriction.
• Cardiac rehabilitation.

Further Presentation (6 months later)

• Sudden onset shortness of breath (SOB).
• Chest X-ray: signs of a pneumothorax.

Investigations (6 months later)

• High Troponin level, (4729 ng/L).
• Likely a pulmonary condition, such as a bullae or pneumothorax.

Type of MI

• The presentation suggests an earlier MI or ongoing MI.

Conclusion

• Patient with multiple and evolving conditions.
• Requires prompt and comprehensive management and a multidisciplinary approach.
• Needs to be closely monitored and managed in light of a potential bullae or pneumothorax.
• Patient needs a review to understand the potential issues.

Respiratory Diagnoses

• Asthma
• COPD
• Pulmonary embolism
• Lung cancer (less likely).
• Pneumothorax
• Pneumonia

Spirometric Findings

• FEV1/FVC ratio less than 0.7, indicates possible obstructive diseases.

• Various stages of Spirometry to show moderate to severe obstructive.

Respiratory Anatomy

• Includes information about the lungs (lobes, fissures, etc.), bronchial tree, and alveoli.

Respiratory Pathophysiology

• Detailed information on Emphysema, including descriptions regarding bullae development.

Treatment Considerations

• Antibiotics (abx).
• Steroids.
• Nebulisers.
• Specimen analysis (sputum sample, urinary antigens).
• Specialist nurse input.
• Aminophylline, NIV.
• Spirometry.

Reasons for Leg Swelling

• Possible pressure from the lungs (pulmonary conditions).

This quiz explores a clinical case involving a 55-year-old male presenting with chest pain and elevated troponin levels. It delves into examination findings, ECG results, and cardiac structure abnormalities such as aortic stenosis. Participants will enhance their understanding of cardiovascular assessment and cases related to myocardial injury.