Acute onset mid-scapular pain

The patient was an 89-year-old gentleman without prior cardiac ischemic symptoms until the morning of 12/07 when at 5:00 a.m. he experienced the onset of non-radiating mid-scapular pain without dyspnea or other symptoms that woke him from rest. He had never had similar symptoms. He was taken to an outside hospital where an ECG (Image 1) suggested acute myocardial ischemia. The patient was emergently transferred to the catheterization laboratory at Johns Hopkins Hospital. After receiving intravenous heparin and eptifibatide he underwent successful angioplasty and stent placement of 90%-95% circumflex and 70% mid LAD lesions.

Past history is notable for atrial fibrillation of several years duration, hematuria while on warfarin three years ago, prostate surgery 10 years ago, and facial melanoma surgery. He also reported nocturia times six and bilateral ankle swelling. He denied angina, claudication, dyspnea, orthopnea, PND, CVA or TIA symptoms. He had no allergies. His father died of a myocardial infarction at 63 years. His mother died of pneumonia in her 80s. He has three siblings who have died of unknown causes.

Atrial Fibrillation
Prostate Cancer (1990)
Facial Melanoma

His father died of myocardial infarction at age 63, his mother died at 80 of pneumonia. He had three siblings who are deceased (? causes).

N/A

Coumadin

No known drug allergies

No additional symptoms

Weight: 130 lbs Height: 6 ft BP: 120/53 P: 80
General: No acute distress
HEENT: EOM intact. Sclera anicteric. Neck supple. Carotids were 2+ without bruits. No lymphadenopathy.
CV: The heart rhythm was irregularly irregular at 80-90 bpm. No gallops or murmurs present.
Lungs: clear without crackles, rhonchi, or wheezes
Abdomen: Soft and nontender. Bowel sounds normal. No palpable masses.
Genitalia: Normal.
Extremities: Venous stasis changes were present bilaterally. Pulses 2+. No pedal edema.

Na 137; K 4.1; Cl 106; CO2 19; BUN 24; Cr 0.8; Glu 129; Ca 7.7;
LDL 120; HDL 20; Total Cholesterol 150; Triglycerides 52
WBC 11240; RBC 3.92; Hgb 12.3; Hct 36.9; MCV 94.1; Plts 162
Urinalysis negative

AP portable chest x-ray (on admission): Cardiomegaly. Aorta with minimal tortuosity. Possible pulmonary vascular congestion.

Post-catheterization he was admitted to the JHH coronary care unit. Peak post-procedure CK was 1896 ug/L (MB= 335 ug/L) and Troponin I was 65 ng/ml. ECG showed resolution of the lateral ST elevations and was interpreted "atrial fibrillation, low voltage QRS (consider pulmonary disease, pericardial effusion, or normal variant)". There was one non-sustained run of ventricular tachycardia noted on CCU monitoring (Image 2).

One day after admission, eptifibatide was discontinued. The patient was noted to have hematuria which resolved after manipulation of the Foley catheter. Heparin was continued. An Echocardiogram was interpreted as showing mild-moderate LV systolic dysfunction (EF 45%), inferior akinesis, posterior larteral hypokinesis, left atrial enlargement, mild-moderate aortic regurgitation, moderate tricuspid regurgitation, mild-moderate mitral regurgitation, mild pulmonary hypertension.

Two days after admission the early AM ECG was unchanged from the day before. At approximately noon, the patient developed melena. His hematocrit fell from 35% to 17%. He was taken for a tagged red blood cell scan after nasogastric lavage failed to identify a source of upper gastrointestinal source of bleeding. The scan showed normal radiotracer distribution, and no scintographic evidence of GI bleeding site. However, while undergoing the scan, he became unresponsive and developed bradycardia with an ECG showing new S-T segment elevations. He could not be resuscitated despite vigorous efforts and expired. An autopsy was performed.

What is the differential diagnosis and likely cause of the terminal event?