Monday, August 11, 2008

Case 13

A 48 years old male with presented to the emergency department with chest pain and diagnosed with acute myocardial infarction. Within one hour of presentation he develops pulmonary edema, which responds to intravenous Furosemide. The patient had cardiac angioplasty, and his chest pain resolved within 2 hours of onset. An echocardiogram shows inferior akinesa, EF 50 %, and trivial mitral regurgitation. 10 hours later, recurrent chest pain developes, and the manifestation of acute pulmonary edema return.

On physical examination, he is afebrile, blood pressure 108/64, pulse 102/min, and respiratory rate is 28/min. No jugular venous distention, cardiovascular exam reveals left sterna edge pansystolic murmur radiating to the axilla, lungs, there is rales over lower one-third of lung fields.

Q- Why did episodic pulmonary edema develop in this patient?

6 comments:

Ranjitha said...

may be due to acute MR

prabodh said...

second MI with papillary muscle rupture and acute mitral regurgitation with left sided heart failure and flash pulmonary edema may be a possibility.

prabodh said...

interventricular septal rupture is also a possibility.

ramashesai said...

Mitral valve rupture with severe MR secondary complication to MI.

uchit said...

papillary muscle rupture

Clinical Medicine said...

The Correct answer is :
The pulmonary edema is secondary to left atrial load in iscemic mitral regurgitation.
- The infarcted papillary muscle fails to contract during systole ,allowing the mitral valve leaflet to prolapse into the left atrium,producing MR.
-The left atrial load secondary to MR,makes pulmonary edema more prominent finding than in acute VSD.
-The murmur in VSD is heared loudest along the sternum and radiate to the right of the sternum.
-This condition occurs more frequently with inferior MI.

Ref
-1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction)
J Am Coll Cardiol 1999 34: 890-911