Case 26: An Acute Myocardial Infarction? You Did What?

At age 62, this lady presented on November 28, 1994 with a 35 year history of insulin-dependent diabetes, a history of multiple foot ulcers and recent chest pain. Foot ulcers on both feet had been treated conservatively in 1988. New lesions led to an angioplasty in the left leg in 1992 and a femoral endarterectomy in the right leg in 1993. Her ankle/arm index in the right leg was now 0.50 and in the left leg 0.98. She had a small superficial ulcer on her right 5th toe. Absent vibration sense, diminished light touch sensation, absent Achilles reflexes and 24-inch two-point discrimination documented the presence of advanced peripheral neuropathy. Demonstrable but diminished PPG waveforms in her toes suggested that, while significant arteriosclerosis obliterans was present, she had adequate basal blood flow to heal her lesions with proper conservative care. The importance of proper shoewear was emphasized. The right toe did heal but she returned complaining both of angina and claudication. She was advised of the standard approaches of our cardiologists: stress-thallium tests, coronary angiograms and either bypass surgery or angioplasty. She refused then and regularly thereafter to consider these procedures as a friend had died on the operating table in following this course. Isordil, coumadin and Tenormin were added to her program without benefit on her angina. Her claudication increased and began to limit her walking around her home. She then agreed to boot therapy which was performed intermittently over the next several months successfully relieving her claudication and at the same time alleviating her angina. She finished the summer and fall in Florida only to return in December again with heavy legs and angina.

On the 26th of December, she had a busy day and noted chest pain persisting through much of the day. She had a poor supper at 6PM and noted persistent more severe pain after the meal. Three nitroglycerine tablets were ineffective. She went to bed hoping for relief. At 11:30 PM she called the medical service advising us for the first time of her severe and persistent pain. She was advised of her options over the phone: (a) if she was sure this was her heart pain, she might go to the Emergency Room where narcotics, heparin, oxygen and heart monitors were available... and where, in view of the fact that she was already anticoagulated and had not benefited from her nitroglycerine, an emergency heart catheterization might be advised if her vital signs were unstable. She preferred to go to the office.

It was a mistake to have allowed her to come to the office. She had quickly deteriorated in getting out of bed. She arrived at 12:30 AM pale, faint, weak and diaphoretic. A fingerstick glucose determination quickly ruled out a hypoglycemic reaction. Her EKG showed new large RST depressions from V2 to V5. Her blood pressure was hard to obtain. She appeared to be in cardiogenic shock.

12.40AM Office EKG - The complexes have been inked over to contrast against the lines in the graft paper.

She and her husband claimed that she still did not want any invasive procedures. She appeared to need immediate help and the therapeutic options available in the Emergency Room appeared unlikely to help her much. Further, it would take perhaps twenty minutes for an Emergency Ambulance to come get her in the office. For legal reasons, the hospital personnel could not come through the halls connecting the office building with the hospital. What to do quickly? She was offered boot therapy and accepted immediately. She was carried to a boot table and positioned supine on it.

The chest electrodes were applied but would not stick to the damp skin; they had to be held in place. The left leg was placed in a boot with the bag extending from her toes to her groin and pumping immediately begun. Within a few minutes her facial color returned to a normal pink. Her pain, however, persisted. She was advised to remember the level of this pain which we would thereafter call a "10". Her husband held the chest electrodes in place while a boot was placed on the right leg. Her skin began to dry and the electrodes stuck. She began to hold a normal conversation and it appeared she was out of trouble. Her pain level slowly receded... "8"... "6"... "5"..."3"..."1"..."1"... "0". She was ready to go home! No, it was insisted, she had to go to the hospital and had to consult with our cardiologists who I would now telephone.

"An acute myocardial infarction and you did what?" exclaimed the cardiologist over the telephone. She might have died in your office! Who would have stood by you in court? At least, in the Emergency Room, there would have been other people to hold her hand!.

Laboratory studies included serial CPK determinations: 274 at 3:15AM, 1194 at 10AM and 438 at 11:59PM. An initial chest x-ray was read as showing mild cardiac decompensation. Serial EKG's showed a slow change of the RST segments back towards normal. An ultrasound of the heart on December 27th showed an ejection fraction of 61% and normal movements of the heart muscle. A thallium myocardial scan on January 2nd showed a alight enlargement of the left ventricle, a perfusion defect in the posterior lateral segment and some apical thinning. A stress persantine test was also accomplished on January 2nd. No ischemic EKG changes were seen.

She was given daily boot treatments to alternate legs throughout her hospitalization and was comfortable throughout her stay. The cardiologists encouraged her daily to consider having coronary angiograms and emphasized her lucky survival. She agreed finally to have a catheterization. A 70% stenosis of the left main coronary artery and a graded 90% stenosis in the proximal portion of the circumflex artery were found. The major marginal branch filled out sluggishly in an antegrade fashion and also filled by left and right collaterals. There were sequential 80% stenoses of the left anterior descending artery after the origin of the second diagonal branch. There was a 90% stenosis in the proximal portion of the dominant right coronary artery and an 80% stenosis of the origin of the posterior descending artery. In the middle to distal portion of the posterior descending artery was another 50% stenosis. Finally, there was a 90% stenosis of the largest posterior lateral branch of the distal right coronary artery. Multiple bypass surgery was recommended and refused. She was discharged January 10th with the following medications: aspirin, Atenolol 25mg daily, Capoten 12.5 mg every 8 hours, Lasix 40 mg daily, Lanoxin 0.25 mg daily and Nitrobid 2.5 mg daily.

She received boot therapy to both legs for two weeks in the office and had the follow-up EKG shown below. Her Holter Monitor (Monitor One TC100 by Q-Med) study showed no significant RST depressions on April 2nd.

Followup EKG February 9th, 1996

Continuous ST Histogram showing no significant depressions

She was also studied in the IQ electrical impedance apparatus where her cardiac output and stroke volume were noted to increase significantly during boot therapy: from 3.73 L/min. to 6.12 L/min. for the cardiac output and from 64.4 ml to 102.1 ml for the stroke volume. Photoelectricplethysmographic tracings of her left big thumb also are included to show the effect of boot decompression of the finger tracing; it is seen to narrow considerably.

First and Third Row are the EKG complexes before and during boot therapy respectively. The Second and Fourth row are the pulse waveforms in the aortic root again before and during boot therapy.

Photoelectricplethysmography Tracings from Thumb before and during Boot Therapy

Comments: We did what? We may have done the only thing that could have saved this lady's life at the moment. It is a shame that malpractice issues may arise in such cases. Therapy with the Circulator Boot obviously can be shown to have a beneficial effect on the heart. The role of such therapy and its place if any in every day therapy is not established... but we find it awfully handy to have around at crucial moments. Again, this case is added to distinguish the Circulator Boot from other boots that are commonly used primarily for the treatment of lymphedema and venous stasis. When this report was written, this lady had continued to do well and was scheduled to return to the office in a few months time for follow-up.