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A case of critical aortic stenosis masquerading as acute coronary syndrome.

Wayangankar SA, Dasari TW, Lozano PM, Beckman KJ - Cardiol Res Pract (2010)

Bottom Line: This case report describes a patient who presented as suspected acute coronary syndrome with markedly elevated troponin levels, who was later found to have normal coronaries and critical aortic stenosis.This case highlights the need for comprehensive and accurate physical examination in patients who present with angina.Careful physical examination will lead to an earlier use of non invasive techniques, such as echocardiography to confirm the correct diagnosis and the avoidance of inappropriate treatments such as intravenous nitroglycerin and glycoprotein IIb/IIIa inhibitors.

View Article: PubMed Central - PubMed

Affiliation: Department Internal Medicine, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd., WP 1130, Oklahoma City, OK 73104-5020, USA.

ABSTRACT
Serum cardiac troponins I and T are reliable and highly specific markers of myocardial injury. Studies have shown that at least 20% of patients with severe aortic stenosis have detectable serum troponins. This case report describes a patient who presented as suspected acute coronary syndrome with markedly elevated troponin levels, who was later found to have normal coronaries and critical aortic stenosis. This case highlights the need for comprehensive and accurate physical examination in patients who present with angina. Critical aortic stenosis may cause such severe subendocardial ischemia as to cause marked elevation in cardiac markers and mimic an acute coronary syndrome. Careful physical examination will lead to an earlier use of non invasive techniques, such as echocardiography to confirm the correct diagnosis and the avoidance of inappropriate treatments such as intravenous nitroglycerin and glycoprotein IIb/IIIa inhibitors.

No MeSH data available.


Related in: MedlinePlus

Echocardiogram showing criteria for critical aortic stenosis.
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Related In: Results  -  Collection


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fig2: Echocardiogram showing criteria for critical aortic stenosis.

Mentions: A forty-nine-year-old otherwise healthy Caucasian male with history of marijuana abuse presented with 12 hours of constant retrosternal, nonradiating chest pain, partially relieved by sublingual nitroglycerine. Physical exam was significant for BP 140/74, heart rate 75 beats/min, carotid shudder, single S2, S4 gallop, and a grade IV/VI crescendo-decrescendo late-peaking murmur in aortic area that radiated to the carotids. These physical examination signs were consistent with critical aortic stenosis. Laboratory work revealed a troponin rise from an initial level of 0.09 ng/mL (normal: <0.4 ng/mL), CK-MB of 3.7 ng/mL (normal: 0–11.2 ng/mL)), to a second troponin value of 26.7 ng/mL which finally peaked at 99 ng/mL (CK-MB of 81.3 ng/mL) within 12–18 hours of presentation. Urine Drug Screen was negative for cocaine but positive for marijuana. A 12-lead EKG revealed sinus rhythm at 75 beats/min with left ventricle hypertrophy and repolarization abnormality (Figure 1) but no acute ST-T changes suggestive of myocardial injury. The classic physical exam findings of aortic stenosis lead us to an urgent echocardiography, rather than an early invasive approach of cardiac catheterization. Echocardiography revealed (Figure 2) an ejection fraction of 55–60%, suspected bicuspid aortic valve with critical aortic stenosis and peak velocity of 5.8 m/sec, a peak transvalvular gradient of 135 mm of Hg (mean gradient of 77 mm of Hg), and an indexed valve area of 0.52  cm2, all of which were suggestive of critical aortic stenosis.


A case of critical aortic stenosis masquerading as acute coronary syndrome.

Wayangankar SA, Dasari TW, Lozano PM, Beckman KJ - Cardiol Res Pract (2010)

Echocardiogram showing criteria for critical aortic stenosis.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2913510&req=5

fig2: Echocardiogram showing criteria for critical aortic stenosis.
Mentions: A forty-nine-year-old otherwise healthy Caucasian male with history of marijuana abuse presented with 12 hours of constant retrosternal, nonradiating chest pain, partially relieved by sublingual nitroglycerine. Physical exam was significant for BP 140/74, heart rate 75 beats/min, carotid shudder, single S2, S4 gallop, and a grade IV/VI crescendo-decrescendo late-peaking murmur in aortic area that radiated to the carotids. These physical examination signs were consistent with critical aortic stenosis. Laboratory work revealed a troponin rise from an initial level of 0.09 ng/mL (normal: <0.4 ng/mL), CK-MB of 3.7 ng/mL (normal: 0–11.2 ng/mL)), to a second troponin value of 26.7 ng/mL which finally peaked at 99 ng/mL (CK-MB of 81.3 ng/mL) within 12–18 hours of presentation. Urine Drug Screen was negative for cocaine but positive for marijuana. A 12-lead EKG revealed sinus rhythm at 75 beats/min with left ventricle hypertrophy and repolarization abnormality (Figure 1) but no acute ST-T changes suggestive of myocardial injury. The classic physical exam findings of aortic stenosis lead us to an urgent echocardiography, rather than an early invasive approach of cardiac catheterization. Echocardiography revealed (Figure 2) an ejection fraction of 55–60%, suspected bicuspid aortic valve with critical aortic stenosis and peak velocity of 5.8 m/sec, a peak transvalvular gradient of 135 mm of Hg (mean gradient of 77 mm of Hg), and an indexed valve area of 0.52  cm2, all of which were suggestive of critical aortic stenosis.

Bottom Line: This case report describes a patient who presented as suspected acute coronary syndrome with markedly elevated troponin levels, who was later found to have normal coronaries and critical aortic stenosis.This case highlights the need for comprehensive and accurate physical examination in patients who present with angina.Careful physical examination will lead to an earlier use of non invasive techniques, such as echocardiography to confirm the correct diagnosis and the avoidance of inappropriate treatments such as intravenous nitroglycerin and glycoprotein IIb/IIIa inhibitors.

View Article: PubMed Central - PubMed

Affiliation: Department Internal Medicine, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd., WP 1130, Oklahoma City, OK 73104-5020, USA.

ABSTRACT
Serum cardiac troponins I and T are reliable and highly specific markers of myocardial injury. Studies have shown that at least 20% of patients with severe aortic stenosis have detectable serum troponins. This case report describes a patient who presented as suspected acute coronary syndrome with markedly elevated troponin levels, who was later found to have normal coronaries and critical aortic stenosis. This case highlights the need for comprehensive and accurate physical examination in patients who present with angina. Critical aortic stenosis may cause such severe subendocardial ischemia as to cause marked elevation in cardiac markers and mimic an acute coronary syndrome. Careful physical examination will lead to an earlier use of non invasive techniques, such as echocardiography to confirm the correct diagnosis and the avoidance of inappropriate treatments such as intravenous nitroglycerin and glycoprotein IIb/IIIa inhibitors.

No MeSH data available.


Related in: MedlinePlus