Case Presentation: A 78-year-old man with medical comorbidities of CAD with PCI to LAD and LCx, persistent A. fib, COPD, HTN, and Type 2 Diabetes Mellitus was admitted to our hospital for worsening epigastric pain, nausea, and vomiting. Prior to the presentation, he was treated for an upper gastrointestinal bleed secondary to duodenal ulcers. Dabigatran for A. fib was held, and he was discharged home. He returned 4 days later with concern of worsening duodenal ulcer disease and GI bleed. On day 3 of admission, he continued to have epigastric pain and subsequently developed new, acute chest pain. The patient was hypotensive and on auscultation was found to have a new harsh, holosystolic murmur that was heard best at the left lower sternal border. The following EKG showed ST-elevations in anterior leads, notably V3-4 concerning for anterior STEMI with occlusion of LAD. Bedside echo demonstrated moderate LV systolic dysfunction with LVEF 30-35%, apical aneurysm, and a new ventral septal defect (VSD). The VSD had 2 components, apical and mid septal. The patient was sent emergently for catheterization which showed a patent proximal LCx stent, totally occluded LAD with left to left apical collaterals, ostial RCA with severe stenosis, and confirmed VSD with Qp:Qs >2 and elevated right-sided filling pressures. Intra-aortic balloon pump (IABP) device was placed in preparation for following emergent VSD repair and CABG with saphenous vein graft to the posterior descending coronary artery. On post-op day 1, the patient developed respiratory failure requiring intubation, cardiogenic shock requiring vasopressors, and recurrent A. fib. The patient was emergently taken back to the cath lab for Impella device. The patient passed with comfort measures only.
Discussion: This case highlights two uncommon presentations that hospitalists should consider with admitted patients. The first is the atypical presentation of an MI. This patient initially presented with epigastric pain secondary to duodenal ulcers with UGI bleed but also with nausea, vomiting, and presyncope. Chest pain has a low positive predictive value for MI in the elderly and atypical MI symptoms increase with age [1]. In ages 75-84, 33% of patients present with MI without typical chest pain, further leading to delayed intervention resulting in increased mortality [2]. Suspicion for underlying MI should be heightened with complaints of dyspnea, diaphoresis, nausea, vomiting, or presyncope [3]. The second feature of this case is the post-MI complication of VSD within 48 hours. Traditionally, this occurs 3 to 5 days post-MI [4]. This is also a rare complication in the age of PCI. Prior to PCI, the incidence of VSD was 1-2%. PCI has decreased VSD complications to 0.2% [5]. Auscultation is simple and of great importance for the detection of a new murmur, usually the first clue for VSD. Highly associated symptoms are chest pain, altered mental status, and decreased urine output [6]. TTE can be used to confirm and evaluate the degree of severity of the VSD. Due to rapid onset and high fatality, collaboration with CT surgery for surgical intervention is needed emergently. In the meantime, manage hemodynamic status with IABP and afterload reduction.
Conclusions: Hospitals should be vigilant in the elderly population for atypical presentations of myocardial infarctions and should also be aware of MI complications that are rare in the age of PCI. With a delay in diagnosis, there is a delay in intervention, leading to suboptimal hospital care with increased morbidity and mortality.