Case - Solver

A 65-year-old man with a history of hypertension, diabetes mellitus, and exertional chest pressure is seen in the ER complaining of sudden onset of chest pain and severe dyspnea at rest. He is currently taking enalapril (5 mg twice a day) to control his blood pressure. Physical examination reveals a pale white male in acute respiratory distress, who is anxious and diaphoretic. His blood pressure is 180/100 mm Hg, his apical pulse is 170 beats per minute and irregularly irregular, and his respiratory rate is 40 per minute. Examination of the lungs reveals rales extending two thirds up from the base of the lung fields bilaterally. Examination of the heart reveals a jugular venous pressure of 12 cm of water, a third sound (S₃), and a grade 2/6 holosystolic murmur heard at the apex. Arterial blood gas determinations performed on room air show a partial pressure of oxygen of 50 mm Hg, a partial pressure of carbon dioxide of 30 mm Hg, and a pH of 7.48. A chest radiograph shows an enlarged heart and pulmonary edema. The ECG reveals atrial fibrillation with a ventricular response of 170 beats per minute, a loss of R waves, and 4 mm of ST elevation anteriorly and findings that are consistent with an acute anterior MI. A diagnosis of acute anterior wall MI complicated by atrial fibrillation and pulmonary edema is made.