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ACCP-SEEK Board Review Question of the Month |

A 64-Year-Old Man Enters the ICU With Hypotension and Pulmonary Edema Associated With Persistent Chest Pain*

Joseph Parrillo, MD, FCCP
Author and Funding Information

*From the ACCP-SEEK program, reprinted with permission. Items are selected by Department Editors Richard S. Irwin, MD, FCCP, and John G. Weg, MD, FCCP. For additional information about the ACCP-SEEK program, phone 1-847-498-1400.



Chest. 1999;116(5):1459-1460. doi:10.1378/chest.116.5.1459
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A 64-year-old man enters the ICU with hypotension and pulmonary edema. He has a 5-year history of intermittent angina treated with nitroglycerin. Two years ago, the patient had an ECG showing T-wave inversions in leads II, III, and AVF. An echocardiogram showed inferior wall hypokinesia, and he was presumed to have sustained an inferior wall myocardial infarction. This morning he developed severe chest pain and came to the hospital. His ECG demonstrated ST-segment elevation in V1 to V4, and he was given aspirin and thrombolytic therapy with tissue plasminogen activator. However, his chest pain continued, and he developed hypotension and pulmonary edema. Pulmonary artery catheterization reveals a cardiac index of 1.7 L/min/m2 and a pulmonary artery occlusion pressure of 32 mm Hg. Echocardiography reveals akinesia of the inferior and anterior walls. An intra-aortic balloon pump is placed, and the patient is taken to the cardiac catheterization laboratory. Angiography reveals severe three-vessel disease with 80% obstruction of the left anterior descending coronary artery, 90% obstruction of the left circumflex artery, and 95% obstruction of the right coronary artery. Three-vessel coronary artery bypass surgery is performed, and the patient’s cardiogenic shock resolves. He goes home on the eighth postoperative day.

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