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PE vs MI

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Please tell me what you guys think of this case. You are called for a 55 year old male for chest pain & shortness of breath. On arrival you find him seated in a recliner rubbing his chest. You notice that he is diaphoretic & pale. He tells you that he was working in the yard & developed chest pain & shortness of breath so he stopped to rest & when he told his wife who is an nurse, she gave him some Aspirin & called 911. Upon exam you note the following. His BP is 85/50, P is 120, RR is 22, Spo2 is 93% & his temp is 98.7. When you perform the 12 lead EKG you notice that he has T wave inversion in V1-V4. (Sorry I don't have a copy of the 12 lead, this is a patient I encountered after the first 911 call.) He was placed on 2 LPM via nasal cannula, an IV of normal saline was started & labs were drawn. The patients exam went as follows: 1. HEENT were WNL. 2. Lungs were slightly diminished with some wheezing noted. 3. Abdomen was soft, non tender. 4. CMS x4, 5. slight pedal edema was noted. PMHX included: Acid Reflux, Reactive Airway Disease & Hypertension. Allegies included: Benadryl, Omnicef & Morphine. Medications included: Albuterol Inhaler PRN, Zantac 150 mg BID & Vasotec 5mg. The patient was given a 250 ML bolus of normal saline for his blood pressure & he was transported to the ED. The small critical access hospital evaluated him & determined that he was suffering an MI. They started cardiac protocol & arranged for transport to an ICU 60 miles away. He was admitted to the ICU by Cardiology for treatment for 24 hours, then to the floor for an additional two days. He was started on 325mg Aspirin, Atenolol 25mg QD, Nitro Patch 0.1mg QD, Combivent Inhaler QID, Nexium 40mg QD & Simvastatin 10mg QD. He was sent home, shortly after arriving home he went to get up from his recliner & collapsed, his wife immediately called 911 & started CPR, he was coded for 1 hour, but failed to respond to any interventions. Cause of death Large PE.

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DVT/PE after a hospitalization is not uncommon.

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This.

Especially after the guy laid in a hospital bed for a couple of days.

Did they ever do any PE studies to rule those out?

Sounds like this was just his time to go.

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DVT/PE after a hospitalization is not uncommon.

The epidemiology of VTE is super difficult.  The risk of DVT/PE in hospital patients and those recently discharged from the hospital is something like 100-120 times the risk in the general community, and several studies have shown that PE is found in about 10% of all hospital deaths (though it is usually only suspected in about 3%).  The are accusations of both under and over-reporting in the literature, so really the picture is pretty cloudy.  What's extra weird though is that prophylaxis against VTE is effective in reducing incidence (by about 50%) but not at all effective in improving mortality.  So, this is a disease that is supposed to kill a lot of people, but when we limit the prevalence of the disease we can't seem to change the number of people who die.  Really odd. 

In regard to the patient in question, it would be interesting to know what kind of work he had done at the hospital (stents?  CABG?  medical therapy only?) and what his ejection fraction looked like at discharge.  His discharge medications are interesting as they don't seem to correspond completely with any of the above (no double anti platelet for stents, no ACE-I for ischemic CM, etc)... it isn't really clear what happened to this guy before he left the hospital from the story and the meds alone.  Still, while PE is certainly more common in this population of patients, it is far from the most common cause of death (which would be arrhythmia).    

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Was he on DVT prophylaxis in the hospital?  Heparin or Lovenox?  Pneumatic compression devices?  I don't work on a cardiac floor but know that DVT prophylaxis is standard on the inpatient units.  It does seem like it was just this guys time to go. :( bummer.

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