A 65-Year-Old Male Experiencing Hypotension and Elevated Troponin

The Cardiology Consult Service was asked to evaluate a postoperative 65-year-old male who underwent a hemicholectomy for recurrent GI bleeding. During the operation he had an episode of hypotension with a systolic blood pressure that decreased into the 70s that lasted approximately 20 minutes; blood pressure normalized after administration of fluids. The postoperative ECG showed nonspecific ST-T abnormalities with 0.5 mm ST downsloping depression in leads V 5-6, different from his preoperative ECG. Serial cardiac markers were sent immediately after surgery, 6, 12 and 18 hours postoperatively.

Consultation was requested due to an elevated TnT.

Preoperatively, the patient had normal functional status. He did not exercise regularly but was able to do his daily activities without difficulty. No prior cardiac evaluations were performed other than an ECG, which demonstrated LVH with minor ST-T changes.

Past Medical History: No prior cardiac history; hypertension, tobacco use

Lisinopril 20 mg per day
Hydrochlorothiazide 12.5 mg daily

Physical examination at the time of evaluation;
Vital Signs BP 125/85 mmHg, HR 82 bpm, respiratory rate 16, afebrile
Neck: no obvious JVD
Lungs: clear, A&P
Cardiac: displaced PMI laterally, RRR, normal S1 and S2, no murmurs
Abdomen: midline incision with sutures, mild tenderness to palpation
Extremities: pulses intact, no edema

Laboratory Data:
BUN/creatinine 18/1.0 mg/dl
Hemoglobin 10.1 (preoperatively was 12.1)
TnT (4th generation assay, 99% percentile 0.01 ng/ml, 10% CV 0.03 ng/ml)

initial <0.01 ng/ml
peak 0.07 ng/ml

What would be your next step to evaluate this patient?

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