A 68-year-old male with a history of coronary artery disease/myocardial infarction treated with a…

A 68-year-old male with a history of coronary artery disease/myocardial infarction treated with a drug-eluting stent and controlled hypertension develops microscopic hematuria and is scheduled for cystoscopy. His medication list includes metoprolol XL 100 mg daily, losartan 50 mg daily, atorvastatin 80 mg daily, and aspirin 81 mg. His preoperative examination is unremarkable, and patient reports exercise capacity 4 METs. Per his instructions from his surgeon, he has continued taking all his medications except for holding his lisinopril and metformin the night before. After an uneventful

A 68-year-old male with a history of coronary artery disease/myocardial infarction treated with a drug-eluting stent and controlled hypertension develops microscopic hematuria and is scheduled for cystoscopy. His medication list includes metoprolol XL 100 mg daily, losartan 50 mg daily, atorvastatin 80 mg daily, and aspirin 81 mg. His preoperative examination is unremarkable, and patient reports exercise capacity 4 METs. Per his instructions from his surgeon, he has continued taking all his medications except for holding his lisinopril and metformin the night before. After an uneventful induction and intubation, the patients blood pressure drops from 132/68 to 70/42 mm Hg, with pulse continuing at 66 beats/min. The patients five-lead electrocardiogram demonstrates sinus rhythm but with new 1 mm ST depressions in his precordial leads. End-tidal CO2 and pulse oximetry are unchanged. The blood pressure does not improve with repeated boluses of phenylephrine and ephedrine, or with a fluid bolus of 500 mL, necessitating vasopressin and epinephrine boluses. Bedside transthoracic echocardiogram demonstrates a hyperdynamic and collapsed LV, no wall motion abnormalities, no valvular lesions, and no pericardial effusion. Decision is made to postpone the patients elective surgery and awaken him. Upon emergence, the patients blood pressure recovers to 124/62 mm Hg and pulse 60 beats/min. The patient is extubated successfully with no neurological sequelae. Which of the following is the most likely etiology of the patients hypotension? A. Hypovolemia B. Medication effect C. Acute myocardial infarction D. Pulmonary embolism

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