Cardiology Case

Wilda, a 40-year-old diabetic woman, was evaluated in the emergency room for chest pain. She
had a history of hypertension and a 30 pack-year smoking history. Her medications included
antihypertensives and cholesterol-lowering agents. She had a prior admission several years ago
for a small, uncomplicated, myocardial infarct. She has had angina for many years, averaging
one bout of angina a week. Her usual angina lasted 10-15 minutes and was relieved by
nitroglycerine.
A cardiologist attempted angioplasty several years ago. This procedure relieved her symptoms
for six months, but eventually exercise-induced angina returned. There were no clinical changes
until two weeks prior to her emergency room admission, when she began having daily anginal
attacks that lasted 30 minutes or more.
Presenting symptoms
In the hour prior to her admission, she had awakened with severe chest pain, nausea, and
dyspnea. There had been severe unrelenting pain for 45 minutes, and it had not been relieved
by nitroglycerine.
Physical Exam
--Vital signs: HR 105, BP 100/50 (her usual BP was about 155/95), temp. 100 degrees F.
--She is obese and diaphoretic (sweating profusely) with pale skin and labored respirations.
--Rales were heard over both lung fields.
Diagnostic work-up
An EKG and serial cardiac markers were ordered.
Serial cardiac serum marker study
Time .........CKIU....CK-MB......CK index.....Troponin
Admission.......150........3.............20.............<0.4
8 hours...........320........8.............25........... ...0.8
16 hours.........500.......30.............60..............10.4
24 hours.........750.......60.............80..............22.0
48 hours.........300.......18.............60..............14.0
72 hours..........80..........2.............25...............9.3

Normal........38-120......0-3............0-3.............<0.4
Serum creatine kinase (CK) is only slightly elevated on admission. The time course of CK
elevation is consistent with that expected for infarct-related release of CK. CK-MB rises and falls
in parallel with CK, as does the CK index, with a peak at 24 hours. In this case, total CK and
CK-MB appear to peak at the same time. In most cases, CK-MB peaks about 6 hours before
total CK and returns to normal levels about 12-24 hours before total CK. Elevated levels of
cardiac troponin, particularly cardiac troponin I, are highly specific markers of myocardial injury.
Note that troponin levels rise in parallel with CK-MB and reach a maximum at the same time
that CK-MB and the CK index peak. In contrast, however, troponin levels remain persistently
elevated after CK-MB and the CK index have returned to normal.
See Attached Image below for sample picture and description of her coronary artery
athersclerosis.
Questions
1. Could you still have made the diagnosis of acute myocardial infarct (MI) based on laboratory
data if the patient had waited 24 to 48 hours before coming to medical attention?
2. Which serum marker is the most specific for myocardial injury and why? (see "Evaluation and
Treatment" discussion in text, pg 607 and Myocardial Cells pg 561.)
3. What kind of angina did this patient have in the week before she presented? Compare the
pathophysiology of stable angina and unstable angina. What events may have taken place in
her coronary arteries?