A CUTE CORONARY SYNDROME Camille Ann L. Asuncion Case Presentation TMC IM-ER.
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Transcript of A CUTE CORONARY SYNDROME Camille Ann L. Asuncion Case Presentation TMC IM-ER.
ACUTE CORONARY SYNDROME
Camille Ann L. Asuncion
Case Presentation
TMC IM-ER
GENERAL DATA TO 71 year old Male Filipino Roman Catholic Currently residing at Pasig City Brought to TMC ER last January 4, 2011
Informant and reliability: Self (good reliability)
CHIEF COMPLAINT
Chest Pain
HISTORY OF PRESENT ILLNESS
8 hours PTC
Chest pain
sudden onset, substernal, nonradiating
occurring at rest
20 minutes duration
10/10 in severity
“more severe now than before”
with associated diaphoresis
No palpitations
No difficulty of breathing
No abdominal pain
No fever
Meds: Isorbide Mononitrate (Imdur) 30 mg tab
HISTORY OF PRESENT ILLNESS
3 hours PTC
Recurrence of chest painsudden onset, substernal, nonradiatingoccurring at rest20 minutes duration10/10 in severitywith associated diaphoresis
Headachediffuse, nonpulsating, nonradiating5/10 in severity
Meds: Isorbide Mononitrate (Imdur) 30 mg tab
Persistence of symptoms
HISTORY OF PRESENT ILLNESS
Rushed to TMC ER
PAST MEDICAL HISTORY (+) Diabetes Mellitus (~ 20 years)
Glimepiride (Norizec) 1 mg OD Sitaglipin 50 g BID
(+) IHD s/p MI (2008) Isosorbide-5-mononitrate (Imdur) 30 mg OD as needed
(+) PTB with pleural effusion (Nov. 2010) s/p ultrasound guided thoracentesis (450 ml, right) currently being treated with Rifampicin 150 mg, INH 75
mg, Pyrazinamide 400 mg, Ethambutol HCl 275 mg (Quadtab) 3 tablets before breakfast, OD
PAST MEDICAL HISTORY No Hypertension No asthma No pneumonia
No allergies No previous surgeries
FAMILY HISTORY (+) Diabetes Mellitus
mother (+) asthma
paternal side
No Hypertension No Pneumonia No TB No Heart disease
PERSONAL AND SOCIAL
Retired businessman
20-pack year smoker 1/2 pack per day
Occasional alcoholic beverage drinker ~2-3 bottles of beer
Denies drug use/abuse
REVIEW OF SYSTEMS Constitutional:Constitutional: no weight loss, no weakness, no fatigue HEENT: HEENT: no dizziness, no blurring of vision, no nosebleeds,
no gum bleeding, no enlarged lymph nodes Respiratory:Respiratory: cough, no dyspnea, no hemoptysis, no
wheezing Cardiovascular:Cardiovascular: no easy fatigability, no orthopnea, no syncope Gastrointestinal:Gastrointestinal: no nausea/vomiting, no change in bowel
habits Genitourinary:Genitourinary: no dysuria, polyuria, no hematuria, no frequency CNS:CNS: no seizure, no tremor Muskuloskeletal:Muskuloskeletal: no muscle/joint pains, no joint swelling Endocrine:Endocrine: no cold/heat intolerance
PHYSICAL EXAMINATION General Survey
Awake, cooperative, not in cardiorespiratory distress
Vital Signs BP 120/70 HR 105 RR 20 T 36.5 °C Pulse Ox: 97% CBG 286
Anthropometrics Height 163 cm Weight 65 kg BMI = 24.4 kg/m2
PHYSICAL EXAMINATION Skin: No lesions. No rashes. No pigmentation or ulcers. HEENT: Eyes: Anicteric sclera, pink palpebral conjunctiva. Ears: No tragal
tenderness. Nose: No alar flaring. Septum midline. No discharge. No sinus tenderness. Mouth: Oral mucosa pink. Tongue midline. No tonsillopharyngeal congestion.
Neck: Supple. Trachea midline. Flat neck veins. No carotid bruits appreciated. Thyroid isthmus barely palpable, lobes not felt.
Lymph Nodes. No palpable cervical lymphadenopathies Chest/Lungs: symmetric chest expansion, no visible retractions, decreased
breath sounds on the right, no rales/crackles, no wheezes Heart: adynamic precordium, No lifets, heaves, thrills. Tachycardic, regular
rhythm, Distinct S1, S2. No murmurs Abdomen: Flat. No surgical scars, no visible veins or pulsations. Normoactive
bowel sounds. No bruits. Tympanitic on percussion. Soft, no tenderness, no organomegaly. Liver edge not palpable. Spleen not palpable.
Extremities: No edema. No cyanosis. No clubbing. Full and equal pulses. No joint deformities. Good turgor (CRT <2 sec.)
PHYSICAL EXAMINATION Neurologic Examination
GCS 15 (E4 V5 M6) Mental Status: Alert and cooperative, thought process coherent, oriented
to person, place, and time. Cranial Nerves: I – not tested; II, III, IV, VI – pupils are 2-3 mm, equally
round and reactive to light and accommodations, full and equal extraocular movements, no nystagmus; V – temporal and masseter strength intact, bilateral facial sensation intact, corneal reflexes not tested; VII – bilateral facial movements intact, taste not tested; VIII – hearing equal for both right and left with finger wistling. X – gag reflex intact; XI – strength of sternocleidomastoid and trapezius muscles 5/5; XII – tongue midline.
Motor: Full range of motion in hands (5/5), wrists (5/5), elbows (5/5), shoulders (5/5), legs (5/5); no involuntary movements.
Cerebellar: Gait – Normal gait. Rapid alternating movements intact. Thumb-index finger pinch movements
Sensory: 100% intact sensation No Kernig’s, No Babinski Reflexes intact
SALIENT FEATURES
71 year old Male Chest Pain
Sudden, substernal, heaviness, 20 min., at rest, with diaphoresis
10/10 “more severe now than before” (+) IHD s/p MI (2008) (+) DM 20-pack year smoker
DIFFERENTIAL DIAGNOSES
ACS STEMI NSTEMI UNSTABLE ANGINA
INITIAL DIAGNOSIS
Acute Coronary Syndrome PTB 3 DM II
ER DIAGNOSTICS
ECG
ER DIAGNOSTICS
ECG: possible inferior infarct CBC
Cardiac Enzymes
Hgb 110 Neut 0.68Hct 0.33 Lymph 0.22WBC 7.3 Mono 0.06PC 304 Eosino 0.04Hypochromic
Trop I (-)CK-MB 14.54 (0-25)CK-MM 11.83 (24-179)CK-Total 26.37 (24-204)
PT: Control vs. Patient 13.3 vs. 14.7 (12-14)% Activity 0.81 (0.7-1.31)INR 1.14
apTT: Control vs. Patient 32.2 vs. 30.8 (28-37)
ER DIAGNOSTICS
Diagnostics ECG CBC Cardiac Enzymes
Crea 0.79 mg/dl Na 136 K 4.4
CXR:
Consider PTB with bronchiectatic changes, right upper lobe, unchanged. Slightly progressing, pleural effusion, right
ER INTERVENTION
Supplemental Oxygen at 2 lpm via nasal cannula
Meds: Aspirin (Aspec-EC) 80 mg tab OD Clopidogrel (Plavix) 75 mg tab OD
Admitted to floors
FINAL DIAGNOSIS
Unstable Angina PTB 3 DM II
CASE DISCUSSION
DEFINITION
Acute Coronary Syndrome Any constellation of clinical symptoms that are
compatible with acute myocardial ischemia Spectrum of disease, due to an imbalance of
myocardial oxygen demand and supply
DEFINITION
complete obstruction of
a coronary artery
damage/necrosis of the full thickness of
the heart muscle
Partial obstruction of
a coronary artery
damage/necrosis of the partial
thickness of the heart muscle
Vs. NSTEMI : severity of ischemia to
cause sufficient myocardial damage;
Cardiac marker (-)
DIAGNOSIS
Risk Factors
Modifiable Smoking Hypercholesterol Hypertension Obesity Diabetes Mellitus Physical Inactivity
Non-modifiable Age Male Family History of early MI
<50 y/o males <55 y/o females
Known CAD
DIAGNOSIS
Signs and Symptoms Prolonged (usually > 30 minutes) constricting,
crushing, squeezing pain retrosternal, radiating to left chest, left arm can be epigastric sense of indigestion Nausea/vomiting (inferior > anterior MI) Palpitations Diaphoresis Sense of “impending doom” *may be asymptomatic in diabetics
DIAGNOSIS
“high likelihood patient” Established CAD by angiography History of CABG or PCI History of MI, CHF Multiple CAD risk factors
DIAGNOSISSTABLESTABLE STEMISTEMI NSTEMINSTEMI UNSTABLEUNSTABLE
Onset Chronic, episodic
new onset (i.e., within the prior 4–6 weeks)Recurrent but more severe
Location Central, substernal
Retrosternal, epigastric Substernal, epigastric
Duration 2-5 minutes > 30 minutes >10 min
Characteristic
Discomfort Constricting, heavySqueezing, CrushingStabbing, burning
occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than previously
Aggravating Exertion, emotions
Exertion, emotions
Alleviating Rest, nitroglycerin
NO
Radiation Shoulder, arm, neck, jaw, back,
left arm Left arm, shoulder, back
Timing Varies Varies at rest (or with minimal exertion)
Severity Varies severe More severe than previous
Associated symptoms
Palpitations, diaphoresis“Sense of impending doom”, sense of indigestion , n/v
Dyspnea
PATHOPHYSIOLOGY
1. Endothelial dysfunction Hypercholesterolemia LDL
particles oxidative modification inflammatory response leukocyte adhesion molecules monocyte adhesion and migration
2. Fatty Streak Phagocytes ingest lipids foam
cells
3. Advanced, Complicated Lesion
Migration of smooth muscle cells - accumulation fibrous cap
PATHOPHYSIOLOGY
4. Unstable Fibrous Plaque Lesion expansion apoptosis,
necrosis
3. Plaque Rupture with thrombus
Clot overwhelms fibrinolytic mechanisms Rupture of fibrous cap thrombosis
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
DIAGNOSTICS
Exercise Stress Testing Walk on treadmill at increasing levels of difficulty Target heart rate = 85% maximum of age (+) CAD
ST elevation ST depression > 1mm in multiple leads Decreased BP Failure to exercise more than 2 minutes due to
symptoms
DIAGNOSTICS
ECG ST elevation
Inferior (II, III, aVF) Anteroseptal (V1, V2, V3) Lateral (V4, V5, V6)
ST depression Posterior (V1, V2)
T wave inversion Ischemia
Manifestations can vary depending on its location in the heart Anterior – LAD Posterolateral – Circumflex
DIAGNOSTICS
Cardiac Markers Troponin I (within 3 hours ~1 week)
Sensitive and specific CK-MB CK-MM CK-Total
TREATMENT
Initial Treatment for all ACS (UA/NSTEMI) Anti-ischemic
Oxygen NTG Morphine Beta blockers
Decrease cardiac oxygen demand Antiplatelet and anticoagulation
Aspirin Clopidogrel Heparin
Unfractionated Low molecular weight
GP IIb/IIIa Inhibitors
TREATMENT
TREATMENT *Thrombolytics are not used in UA or NSTEMI because
in 60-80% the infarcted artery is not occluded.
STEMI Early revascularization with thrombolytics
Streptokinase, Urokinase, etc.
and/or cardiac catheterization and stent elevated troponin Recurrent chest pain despite medical therapy CHF Positive stress test Left ventricular EF< 40% Sustained ventricular tachycardia Cardiac stent within 6 months
PROGNOSIS
PROGNOSIS
TIMI Risk Score Age >= 65 years >= 3 risk factors for
CAD Prior coronary stenosis
>= 50% Presence of ST
segment deviation on admission ECG
At least 2 anginal episodes in last 24 hours
Elevated serum cardiac biomarkers
Use of aspirin prior seven days
PUBLIC HEALTH AND PREVENTION
Promote Healthy Lifestyle DIET modification Smoking cessation Diabetes management Hypertension control
ACUTE CORONARY SYNDROME
Camille Ann L. Asuncion
Case Presentation
TMC IM-ER