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A 50-Year-Old Female, Diabetic Patient with Chest Pain and Dizziness

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A 50-Year-Old Female, Diabetic Patient with Chest Pain and Dizziness | Case Presentation | No. 12-2019 | A 50-year-old female, diabetic patient with chest pain and dizziness Redoy Ranjan, Dharmendra Joshi, Mohammad Ata Ullah, Prashant Bajracharya, Sanjoy Saha and Asit Baran Adhikary Article Info Presentation of Case Based on the history, physical examinations and investigation findings, we would like to Department of Cardiac Surgery, Faculty Dr. Dharmendra Joshi (Resident): A 50-year-old draw a provisional diagnosis. of Surgery, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, female got admitted on June 18, 2019 with Bangladesh (RR, DJ, MAU, SS, ABA); complaints of central chest pain for three years Department of Cardiology, Faculty of and dizziness for the last two months. The chest Provisional Diagnosis Medicine, Bangabandhu Sheikh Mujib pain was compressive in nature, moderate to Medical University, Shahbag, Dhaka, Bangladesh (PB) severe in intensity and radiating to the medial Triple vessel coronary artery disease with com- side of the left upper limb and neck. It used to plete heart block get aggravated during exertion and initially relieved by taking rest but later she had to take medicine to relieve the chest pain. The pain was Differential Diagnosis For Correspondence: not associated with meal, palpitation, dysp- Redoy Ranjan [email protected] noea, cough or fever. She also complained of Angina pectoris dizziness and easy fatigability while walking Dr. Redoy Ranjan (Assistant Professor): The for the last two months. But she never suffered pathophysiology of angina pectoris is myocar- Received: 18 November 2019 syncope or loss of consciousness. She had deve- Accepted: 5 December 2019 loped non-ST elevated myocardial infarction dial ischemia resulting from an imbalance Available Online: 23 December 2019 about three months back. She was known as a between blood supply and oxygen demand of case of hypertension and diabetes mellitus myocardium. Typical clinical features of angina pectoris include retrosternal chest discomfort ISSN: 2224-7750 (Online) under medications for the last ten years. She 2074-2908 (Print) had no other known chronic illness like bron- which may be described as compressing, heavi- chial asthma, bleeding dyscrasias and had ness, squeezing, burning or choking sensation. DOI: 10.3329/bsmmuj.v12i4.44274 never undertaken any major surgical proce- Some may complaint of frank pain lasting for dure. just about 1-5 min, which may be localized in Keywords: Chest pain; Diabetis; Dizzi- the epigastrium, neck, jaw, back or shoulders ness Her general examinations revealed otherwise and precipitated by some sort of exertions and normal finding except she had pale complexion relieved by rest or medication (nitroglycerin) Cite this article: with moderate anemia and her pulse was 55 per and the intensity of pain is constant with res- Ranjan R, Joshi D, Ullah MA, Bajracharya min, regular but low volume. Her blood P, Saha S, Adhikary AB. A 50-year-old piration, cough or posture change. female, diabetic patient with chest pain pressure was recorded (160/60 mmHg). All the and dizziness. Bangabandhu Sheikh systemic examinations viz cardiovascular, res- The clinical examinations of the patients with Mujib Med Univ J. 2019; 12: 187-191. piratory, abdominal and central nervous sys- angina pectoris may be normal. However, some tems revealed normal findings. Then she was patients may show positive Levine test and signs of diffuse atherosclerosis due to abnormal Copyright: further investigated with routine and specific The copyright of this article is retained investigations (Table I). All preoperative labora- lipid metabolism. Chest X-ray may be normal by the author(s) [Atribution CC-By 4.0] tory investigations, chest X-ray, electrocardio- but the patients with previous myocardial graphy, echocardiography and coronary angio- infarction, ischemic cardiomyopathy, pericar- dial effusion, etc. may show cardiomegaly. Available at: graphy were performed. Hemoglobin level was www.banglajol.info 7.6 g/dL which was corrected to 11.6 g/dL by Recently, graded exercise stress testing is utili- blood transfusion (2 units) before operation. zed widely along with ECG, echocardiography A Journal of Bangabandhu Sheikh Mujib Her fasting blood sugar was within normal or myocardial perfusion scintigraphy. Coronary Medical University, Dhaka, Bangladesh limit with antidiabetic medications. She had artery calcium scoring by fast computer tomo- also urinary tract infection as revealed by urine graphy may be employed in selected cases. The diagnostic test is coronary angiography which examination which was treated preoperatively. The chest X-ray was normal. ECG showed helps to assess the anatomic extent and mea- complete heart block with left bundle branch sure the severity of coronary artery disease.1 block (Figure 1) but echocardiography finding Myocarditis was normal with 65% left ventricular ejection fraction. Coronary angiography diagnosed the Dr. Md. Ata Ullah (Medical Officer): Myocarditis case as triple vessel coronary artery disease is a challenging differential diagnosis because it (Table II). quite well resembles an acute coronary 188 BSMMU J 2019; 12: 187-191 syndrome including an ST-segment elevation myo- Table I cardial infarction. Easily available tests like echo- cardiography and cardiac serum biomarkers may be Laboratory data normal and even if abnormal, it is not reliable with enough specificity to differentiate acute coronary Variables Findings Reference range syndrome and myocarditis. If coronary angio- Hemoglobin (g/dL) 7.6 11.5-16 graphy shows no atherosclerotic stenosis or occlu- sions, an endomyocardial biopsy could be the gold Total count (x109/L) 11.0 4.0-11.0 standard to diagnose myocarditis. However, it Differential count could not be used in all patients because of its Neutrophil (%) 62 40-70 invasiveness and limited sensitivity. Nuclear techni- ques may be used with high sensitivity but limited Lymphocyte (%) 33 20-40 specificity for the diagnosis of myocarditis. How- Monocyte (%) 3 02-08 ever, it is not easily available and there are risks of radiation. Cardiac magnetic resonance is currently Eosinophil (%) 2 01-07 one of the safe non-invasive modalities for diag- Basophil (%) 0 00-01 nosis of myocarditis, even in patients with an acute ESR (mm in 1st hour) 81 00-15 (f) coronary syndrome like presentation and normal coronary angiography finding, because it can iden- ABO “A” Positive tify alternative etiologies and detect myocardial edema, hyperemia, necrosis and fibrosis in a safe VDRL Non-reactive and reproducible fashion.2 HBsAG Negative Bradycardia and other forms of heart block Anti-HCV Negative Dr. Sanjoy Saha (Consultant Anesthesiologist): The sinus rhythm with a rate of less than 60 beats per Anti-HIV Negative min is called sinus bradycardia, with uniform and Bleeding time (min) 3 min 30 sec 2-7 min normal P wave, PR interval and PP intervals. The sinus bradycardia may be normal in some indivi- Clotting time (min) 5 min 30 sec 6-9 min duals like highly trained athletes may have a Serum creatinine (mg/dL) 1.1 0.5-1.3 normal heart rate of 30-40 beats/min, due to increa- sed vagal tone. Bradycardias may be either regular Serum bilirubin (total) (mg/dL) 0.4 Adult up to or irregular. First and third-degree heart blocks 1.1 mg/dL usually show regular bradycardia. Electrophysio- Serum aspartate transaminase (U/L) 44 14-63 logically, first-degree heart block may be defective HbA1c (%) 6.0 <6.1 in anywhere among the atrial fibers, the AV node or the His-Purkinje system. TSH (uIU/mL) 0.50 0.3-4.5 International normalized ratio 1.08 Second-degree heart block is usually presented with an irregular rhythm. However, some of the patients may sometimes have a regular rhythm as well. It can be classically categorized into two types viz Mobitz Type I and II. ECG of second-degree AV block may reveal normal P waves and QRS complexes but the QRS complexes are not regularly followed by some P waves. It indicates that atrial impulses are not reaching ventricles. However, the dropped beat may be observed when PR interval progressively lengthens until an atrial impulse failed to reach the ventricle which represents a non- conducted P wave. Third-degree heart block is also known as complete heart block and it usually has regular rhythm with ECG showing constant PP and RR intervals, but variable PR intervals. In complete heart block, the atrial pacemaking may be from SA node or ectopic which could be tachycardic or bradycardic while the lower pacemaking may be junctional or ventri- Figure 1: ECG of the patient showing complete heart block with left bundle cular. The width of QRS complexes and ventricular branch block contraction rates are determined by the location of BSMMU J 2019; 12: 187-191 189 Table II ssive or squeezing type of chest pain radiating to neck, epigastrium or left side of arm. The physical findings may be normal or the patients may have Coronary angiogram findings regular or irregular heartbeat with bradycardia of Vessels Findings variable rate depending on the type of heart block. Left main Normal The case should be further evaluated with different investigation modalities.11, 12, 19 Left anterior descending 70-75% lesion at distal part Left circumflex 80-85% osteo-proximal lesion. Narrow caliber Dr. Ullah: What investigation modalities will you vessel with 70-75% lesion at mid part choose to confirm your diagnosis? Right coronary artery Dominant vessel. 85-90% lesion at mid part Dr. Ranjan: With the fact that coronary artery with distal chronic total occlusion disease
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