Case 50
Death after coronary stenting
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Presentation
The patient was an elderly African American man with diabetes, hypertension and unspecified cardiac disease treated with multiple medications including diuretics.
The patient did not take his diuretic medicine for two weeks during which time he developed bilateral leg swelling.
He went to a covering physician who advised the patient to return home and elevate his legs.
The leg swelling worsened and the patient was admitted to the hospital.
Initial hospital course
The patient was treated with diuretics.
This decreased the leg swelling on the left.
The swelling remained on the right and worsened with weeping through the skin.
The patient had concurrent symptoms of bradycardia.
Later hospital course
Three days after admission, the patient had a cardiac catheterization which showed blockage of the right coronary artery.
The blockage was “severe” and stented with two “small stents.”
Day of death
The following day, the patient underwent cardiopulmonary arrest.
He received advanced cardiac life support measures but died.
The history is obtained from the family.
Discussion Questions
1. What symptoms of heart failure did the patient have?
2. What is the differential diagnosis of bradycardia?
3. Can coronary artery disease cause bradycardia? How?
4. Can bradycardia cause symptoms of congestive heart failure? How?
5. Does the location of the patient’s blockage explain all of the patient’s symptoms? Why or why not?
6. Would you have performed the cardiac catheterization?
7. What other testing would you have requested in this case?
8. Why do you think the patient died?
9. Do you think the patient would have died without the procedure?