12-20-2008, 04:18 PM
A 60-year-old man is evaluated in the emergency department for chest discomfort that has been present on and off for 6 hours. The patient is treated with aspirin, intravenous β-blocker, and intravenous nitroglycerin. Despite this treatment, the chest pain persists. The initial electrocardiogram is shown (Figure 1). Initial troponin and creatine kinase“MB levels are elevated.
The patient is taken urgently to the cardiac catheterization laboratory and coronary angiography is performed. An acute occlusion of the proximal right coronary artery is detected. Percutaneous intervention is successfully performed with dilation and subsequent stent placement.
The following morning, the patient is doing well and is without complaints. During the day, however, gradually progressive hypotension is noted. Physical examination demonstrates a heart rate of 60/min and a blood pressure of 78/60 mm Hg . The jugular venous pressure is elevated to the angle of the jaw; the wave form is indistinct. The apical impulse is normal, and a parasternal impulse is present. Normal S1 and S2 are heard. An S3 and a brief systolic murmur are heard along the left sternal border. The lungs are clear. An electrocardiogram is performed and is unchanged from the previous study.
What is the most likely cause for this patient's current findings?
A Acute cardiac tamponade
B Aortic dissection
C Left ventricular free wall rupture
D Right ventricular myocardial infarction
E Progressive coronary ischemia
The patient is taken urgently to the cardiac catheterization laboratory and coronary angiography is performed. An acute occlusion of the proximal right coronary artery is detected. Percutaneous intervention is successfully performed with dilation and subsequent stent placement.
The following morning, the patient is doing well and is without complaints. During the day, however, gradually progressive hypotension is noted. Physical examination demonstrates a heart rate of 60/min and a blood pressure of 78/60 mm Hg . The jugular venous pressure is elevated to the angle of the jaw; the wave form is indistinct. The apical impulse is normal, and a parasternal impulse is present. Normal S1 and S2 are heard. An S3 and a brief systolic murmur are heard along the left sternal border. The lungs are clear. An electrocardiogram is performed and is unchanged from the previous study.
What is the most likely cause for this patient's current findings?
A Acute cardiac tamponade
B Aortic dissection
C Left ventricular free wall rupture
D Right ventricular myocardial infarction
E Progressive coronary ischemia