Cyclist With Generalized Weakness - Page #4

Working Diagnosis:
Rule out myocardial infarction

Oxygen placed while awaiting ambulance at 4 liters per minute via NC and aspirin 365mg given(chewed and swallowed).
Initial EKG in ambulance revealed ST elevation of 0.5-1mm in leads II, III, and aVF with poor R-wave progression in V1-V4 concerning for ST-elevation myocardial infarction (photo 1 - first EKG at hospital).
Catheterization at hospital revealed 100% stenosis of mid-LAD just distal to first diagonal (photo 2). Thrombectomy with stenting and balloon angioplasty performed with 0% residual stenosis (photo 3). One hundred percent stenosis of 2nd diagonal (photo 3). Balloon angioplasty improved residual stenosis to 20% (photo 4). Ventriculogram demonstrated anterolateral akinesis and apical akinesis with estimated ejection fraction (EF) of 35%.
Initial lab work:
Total cholesterol: 156, Triglyceride: 38, HDL: 66, LDL: 82
CK: 1989(49-348U/L), CKMB: 270(

Coumadin discontinued at 4 weeks by primary cardiologist.
Repeat echocardiogram at 6 weeks revealed normalized EF without akinesis.
He was started on ezetimibe every other day as LDL remained above 70 (74) and niacin due to elevated lipoproteins in an effort to aggressively reduce cholesterol levels for one year. The cardiologist was hopeful that this might help improve his intimal thickness and further reduce the incidence of future events.
He remains on clopidogrel, aspirin, lisinopril, metoprolol, and fish oil.
He began training 10 weeks later with a goal to keep HR

Author's Comments:
Acute myocardial infarction needs to be included in the differential diagnosis of older athletes with chest pain, even those in top physical conditioning.

It is possible to return to elite athletics even after sustaining a myocardial infarction.

Competitive cyclists are at high risk for collision and falls, and therefore have an increased risk for bleeding. Many cardiologists keep patients with drug-eluting stents on clopidogrel for life due to an increased risk of late stent thrombosis (LST) versus bare metal stents (BMS). BMS should be considered in competitive cyclists as clopidogrel may be discontinued sooner with less risk of LST.

ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. Journal of the American College of Cardiology. 2009:54(23),2222-2223.

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