Silent MI

Patient Presentation
E.O., a 78 year old female, was admitted to the general surgery floor directly from the PACU following a total gastrectomy and Roux-en-y anastomosis for treatment of gastric cancer. She had experienced no acute events in the PACU. She was placed on telemetry monitoring on the floor, due to a history of controlled A-fib, and a Dilaudid® bolus PCA for pain control. On the floor, she only complained of 3/10 incisional pain, and quickly fell asleep. Vital signs were stable, and her tele was consistently reading normal sinus rhythm. Approximately five hours after arriving to the floor, her tele monitor showed a four beat run of ventricular tachycardia, which then returned to sinus rhythm. E.O. was sleeping comfortably at this point. She was awakened, and stated she felt no new pain, other than tenderness at her abdominal surgical site.

Differential List
MI, electrolyte imbalance

Diagnosis
An EKG was immediately done, which showed sinus rhythm but with marked ST elevation. Chemistry, CBC, and cardiac enzymes were drawn. Chemistry, CBC, and cardiac enzymes were all within normal levels except for troponin, which was elevated at 40.0.

Treatment
Serial cardiac enzymes were ordered, as well as a chest x-ray, a heparin drip, and aspirin. Within the hour, E.O. had been transferred via helicopter to another hospital to obtain a cardiac catheter.

Outcome
Two days later, E.O. returned to the surgical floor from the outside hospital. She had received a cardiac cath, and had been diagnosed as having had a silent MI. Throughout the remainder of her hospital stay, she experienced no new cardiac symptoms. She remained on a tele monitor until discharge, and only showed normal sinus rhythm or occasional sinus arrhythmia. Her surgical course progressed well and she was discharged seven days after her surgery.