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Cardiac Case: 57-year-old Man with Substernal Chest Pain

by Joseph Alpert, MD

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    00:00 The first patient is a 57-year-old man who's having chest pain comes to the emergency room.

    00:07 He's a sausage maker, he's admitted to the hospital following thirty minutes of severe pain under - substernally under his breast bone. He has chest pressure.

    00:17 It’s not actually being stuck with a needle or burned but it is very uncomfortable and he doesn’t feel it in his neck or his arms.

    00:24 He has a number of atherosclerotic risk factors.

    00:28 He has an elevated LDL cholesterol at 200 mg/dl, no surprise since this is a sausage maker; he's probably eating a lot of animal fat products. He smokes one pack of cigarettes per day and has done so since the age of 14. He has a physically demanding job, but he does no other exercise.

    00:48 Recently he was started on the statin drug by his primary care doctor but he doesn’t take any aspirin or anything else.

    00:55 On physical exam, he has a prominent fourth heart sound so that’s - let me imitated that for you.

    01:02 So the normal heart is, lub-dub, lub-dub, lub-dub - the fourth heart sound is, vlub-dub, vlub-dub, vlub-dub - a little sound just before the first heart sound it implies stiffness in the ventricle and almost any heart disease can do that.

    01:17 He's a little bit short of breath, has respiratory distress and there's some crackles that are third on the way up the back implying some left ventricular failure and he has a grade 2/6 holosystolic mitral regurgitation murmur heard at the apex which goes sort of like this whoo, whoo, whoo.

    01:38 And he has a third heart sound so that’s the timing here's normal, lub-dub, lub-dub, here's with the third heart sound, lub-dubd, lub-dubd, lub-dubd.

    01:50 So his pressure in his chest we suspect is angina or even the pain of a myocardial infarct.

    01:59 He has risk factors for cardiovascular disease, he has signs of left ventricular pathology with fourth heart sound as I said stiffened left ventricle.

    02:09 He has signs of left-sided heart failure and here's his EKG.

    02:15 Take a look at the EKG for a moment and see what abnormality you see in it.

    02:28 The abnormalities are ST elevation in leads V1, V2 and V3 and you can see the normal below that and the ST elevation above it and this is an acute ST elevation myocardial infarction often called a STEMI.

    02:44 Does he need other diagnostic test? In fact the only diagnostic test he needs is a quick trip to the catherization laboratory with a coronary angiogram to find the obstructed coronary artery and open it.

    02:57 Sometimes it takes the cath lab a little while to get set up so you could do an echo to see how bad the ventricle has been affected but usually we’ll do that after the procedure.

    03:08 The patient goes to the cath lab as quickly as possible to reopen the occluded coronary artery in this case the left anterior descending using percutaneous coronary artery angioplasty, he will almost certainly receive a stent in the area of the occlusion.


    About the Lecture

    The lecture Cardiac Case: 57-year-old Man with Substernal Chest Pain by Joseph Alpert, MD is from the course Cardiovascular Cases.


    Included Quiz Questions

    1. The left atrium pushing against a stiff left ventricular wall
    2. Increased filling pressure and dilated ventricles
    3. The closing of the aortic and pulmonary valves
    4. The closing of the mitral and tricuspid valves
    5. Aortic regurgitation
    1. Cor pulmonale
    2. Respiratory crackles
    3. Dyspnea
    4. Mitral regurgitation
    5. Third heart sound

    Author of lecture Cardiac Case: 57-year-old Man with Substernal Chest Pain

     Joseph Alpert, MD

    Joseph Alpert, MD


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