New ST Elevation and elevated trops due to aortic stenosis

2 days later:

Left Ventricle Summary

Decreased left ventricular systolic performance .

Regional wall motion abnormality-distal septum anterior and apex .

Regional wall motion abnormality-distal inferior wall .

Regional wall motion abnormality-anterolateral .

Left ventricular hypertrophy concentric .

90+ year old female with a past medical history of multiple risk factors for ASCVD but no known history of cardiac disease admitted with sacral fracture following a mechanical fall. Since then, had been tachycardic and more short of breath. ECG on 12/27/2017 showed ST elevation in leads V1-V2, slightly increased from baseline, and prior Q waves in septal leads. The Q waves were old and consistent with prior septal MI. The ST elevation was felt to either represent a coronary process, RV strain from PE, and others. A TTE was ordered which showed severely reduced LVEF with normal LV dimensions, probably severe aortic stenosis (gradient and velocity underestimated due to poor LV function and low stroke volume), and multiple WMA's suggestive of ischemic cardiomyopathy verus stress cardiomyopathy. Given the patient's age, lack of chest pain, and clinical appearance more consistent with acute heart failure, elected not to pursue ischemic evaluation or coronary angiography at this time. Consideration was given to right heart strain in the setting of PE (high likelihood with trauma, age, bed-bound, and sinus tachycardia) but this was not corroborated on TTE given normal appearance and function of base of RV (although does have decreased function of distal free wall and apex). Stress cardiomyopathy is a consideration given appearance of LV on TTE, normal LV dimensions, and clinical scenario. Finally, another possibility is LV dysfunction from long-standing severe AS. In addition to all of the above, has been having intermittent SVT with what appears to be atrial tachycardia and atrial fibrillation. Mainstay of therapy at this time is diuresis given clinical heart failure on exam and significantly dilated IVC on TTE and rate control.  New positive blood culture for MSSA bacteremia and being evaluated by ID. As of 12/30/2017, patient made comfort care. Only cardiac medications to be continued are diuretic and beta blocker for comfort, latter due to high risk of pulmonary deterioration with uncontrolled tachycardia.