Coronary Artery Disease - STEMI Case #4

A 66-year-old female presents to the ED with chest pain, shortness of breath, nausea and vomiting. She has had symptoms for 3 days and thought it was indigestion; however, it is now worse. Her temperature is 99.2, blood pressure 140/90 mm Hg, heart rate 70 beats per minute, respirations 20 per minute and oxygen normal on room air. She has an S4 heart sound, but no murmurs are appreciable. Her ECG is below.

Inferior-STEMI-4

She is treated appropriately for an acute inferior wall myocardial infarction with aspirin, clopidogrel, heparin, a beta-blocker, oxygen and percutaneous coronary intervention of the right coronary artery.

On day two of her hospitalization, she becomes acutely short of breath. She remained afebrile with a heart rate of 90 beats per minute, respirations 36 per minute and blood pressure 80/40 mm Hg. Physical examination revealed once again an S4 heart sound and no murmur. Her pulsus paradoxus is 8 mm Hg. A chest X-ray showed pulmonary edema. She is brought back for coronary angiography and her stent in the right coronary artery remains patent. Right heart catheterization reveals a large V wave in the pulmonary capillary wedge tracing. The oxygen saturation measured in the right atrium was 65%, right ventricle 66% and pulmonary artery 65%.

Which of the following is the correct diagnosis?

A. Acute ventricular septal defect

B. Acute left ventricular free wall rupture

C. Acute mitral valve regurgitation

D. Right ventricular infarction

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