CABG (Coronary Artery Bypass Graft)
Patient Presentation:
Patient is a 65-year-old left-handed female with a history of hypertension, a left renal malignant mass s/p left laparoscopic nephrectomy, and hypothyroidism who presented to the ER with complaints of a sudden onset severe chest sharp pain of 10/10 radiating to her left jaw, not relieved by rest. The pain was associated with diaphoresis. Patient was alert, and oriented on assessment and denied fevers, chills, nausea, vomiting, and coughing. On auscultation, lung sounds were clear and normal S1 and S2 heart sounds were heard. Vital signs were: BP 157/81, HR 55, RR 20, temperature 35.9°C, and O2 sat of 100% on 2 liters of oxygen via nasal cannula.
Differential diagnoses:
Pulmonary embolism, unstable angina, pneumothorax, myocardial infarction
Labs and Diagnosis:
STAT EKG revealed normal sinus rhythm, left ventricular hypertrophy with QRS widening, and repolarization abnormality. Lab results were as follow: BUN 22, creatinine 1.5, Cl- 109, Hct 33%, RBC 3.27, Hgb 10.6, WBC 5.5, troponin-I 0.424, and cholesterol 225. Chest x-ray and CT scan were unremarkable. Noninvasive stress test was abnormal. Cardiac catheterization revealed critical multivessel coronary artery disease (CAD). Echocardiogram revealed an EF of 30% without significant valve disease.
Treatment:
An acute non-ST segment elevation myocardial infarction (NSTEMI) secondary to multivessel CAD was ruled in. An IABP was placed to reduce the workload of her heart, allowing her heart to pump more blood, and an urgent cardiac surgery was recommended. Cardio-thoracic consults recommended an urgent coronary artery bypass graft x 4.
Coronary artery bypass graft is a surgical procedure where veins or arteries from elsewhere in a patient’s body are grafted to diseased coronary arteries to bypass atherosclerotic narrowing and improve the blood supply to the coronary circulation.
Outcome:
Patient successfully underwent the procedure. Once medically stable, the patient was discharged home on PO aspirin and Plavix® to prevent blood clots, levothyroxine for hypothyroidism, and Crestor® for her elevated cholesterol. Patient was also provided education on the importance of exercising, consuming a well-balanced diet, and complying with prescribed medications to prevent future MIs and other complications.
Case created by Nafisa Jiddawi, 2012.