1 / 37

case presentation Done by :AHDAB KHAYAT

case presentation Done by :AHDAB KHAYAT. Myocardial infarction. Cellular death or necrosis of cardiac muscle and surrounding tissue secondary to severe or prolonged ischemia. Epidemiology. 1.5 million Americans have an AMI each year

salome
Télécharger la présentation

case presentation Done by :AHDAB KHAYAT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. case presentation Done by :AHDAB KHAYAT

  2. Myocardial infarction • Cellular death or necrosis of cardiac muscle and surrounding tissue secondary to severe or prolonged ischemia.

  3. Epidemiology • 1.5 million Americans have an AMI each year • Mortality ranges from 10 to 15 % during the first year , decrease to 3.5 % per year

  4. Pathophysiology • Atherosclerosis • thrombosis • Myocardial necrosis

  5. Etiology • Coronary thrombosis due to ruptured plaque including platelet aggregation • Coronary artery spasm • Embolic infarction • Cocaine induced vasospasm

  6. Clinical presentation Acute chest pain or discomfort Radiated to an upper extremity Associated with diaphoresis , nausea and vomiting

  7. Chest pain • Gradual in onset • Provoked by an activity • Not change by position or respiration • Difficult to localize • Last longer than 30 min

  8. Risk factor • Family history of CHD • age • sex • DM • hypertension • hyperlipidemia • cigarette smoking • cocaine use

  9. Diagnosis • ECG • Cardiac enzyme monitoring -CK MB : 3-6hr, peak12-24hr normal 36-48hr -LDH : 24-48hr, peak 3-6d -Troponins : late marker

  10. complication • CHF • Cardiogenic shock • Myocardial rupture • Dysrhythmia • Deep venous thrombosis • Pulmonary embolism

  11. Goals of therapy • Limit extension of myocardial necrosis • Prevent reinfarction • Control complications -pain -hyper or hypotension -CHF -ventricular irritability

  12. Nonpharmacologic therapy • Bed rest during first 24hr after acute eventdecrease myocardial O2 consumption prevent extension of infarction during healing • Start low saturated fat and cholesterol diet • Stop smoking

  13. Treatment plan • O2 2-4 L/min Is administered unless the patient has sever chronic obstructive pulmonary disease • ASA antiplatelet effect 325 mg po then 162mg po or plavix 75 mg po (ASA allergy) or ASA 325 mg then 81-162 mg OD + plavix 300 mg then 75mg po OD

  14. Nitrates to relieve ischemic pain Nitroglycerin infusion 10mcg/min syst>90 or SL 0.4 mg q5min up to 3 tab or spray 0.4 mg/aerosol q5min BID

  15. Heparin as adjunctive therapy to prevent rethrombosis 60U/kg IV push then 15U/kg/hr IV infusion (monitor APTT ) • Glycoprotein IIb/IIIa blocker in high risk patient Eptifibatide 180mcg/kg IVP then 2mcg/kg/min for 48-72hr

  16. B blocker slow the heart -atenolol 5mg Iv then 50-100mg po -esmolol 500mcg/kg Iv over min then 50mcg/kg/min Iv infusion ..HR>60

  17. ACEI prevent a build up of fluid by interfering with the enzyme 'angiotensin' which is involved in regulating body fluid lisinopril 2.5-5 mg increase to 10-20mg benzapril 10mg

  18. Long acting nitrate - nitroglycerin patch -isosorbide dinitrate 10-60mg po TID Or isosorbid mononitrate 30-60 mg

  19. Statin -atorvastatin 10mg q HS -simvastatin 40 mg q HS

  20. Symptomatic -morphine 2-4mg Iv prn chest pain -acetamenophin 325-650mg q4-6hr prn headache -lorazepam 1-2 mg TIDprn anxiety -zolpidem 5-10 mg qhs prn insomnia -docusate 100mg BID -famotidine 20mg Iv BID

  21. Cardiac catheterization • An early invasive approach in patient at intermediate to high risk and those in whom conservative management has failed

  22. The patient’s case J.Z 50Y Dr. Nabil AL Ama

  23. J . Z is a 50 years old male admitted at 30/9 under Dr Nabil Al Ama diagnosed with MI • He is married , non smoker • No family history of IHD

  24. PMH : history… DM , HTN , unstable angina dyslipidemia 3 days back discharge..unstable angina plavix, ASA, capotin, atenolol, isordil neurobion, amlor, amaryl, lactulose zocor.

  25. CASE ER 30/9/2006 CC : sever chest pain

  26. Treatment plan

  27. Lap result

  28. Drug interaction • Hypoglycemic effect enhanced by ACEI • Hypoglycemic effect enhanced by NSAIDs • B blocker mask sign of hypoglycemia • ACEI,B blocker,Ca blocker and nitrate enhance hypotensive effect • Plavix enhance bleeding risk with ASA and heparin

  29. recommendation • Close monitoring of BP and glucose level • Start diabetic diet • Replace oral hypoglycemic by insulin  glucose level not controlled • Decrease dose of pantoprazole to 20mg/d ( prophylaxis of NSAIDs ) • Replace lactulose by bisacodyl 5-10mg at night or docusate 100mg BID….DM • WT reduction for cardiac catheterization

  30. References • Christopher T, Alexander M, Sukhdev C: The hand-on guide to clinical pharmacology. 2nd ed.USA: Blackwell; 2005 • Parveen K, Michael C: Clinical medicine.5th ed.UK: W.B.Saunders; 2002:701-832 • Seymour K, Eli DE: Clinician’s handbook of prescription drugs. International ed.USA:Mc-Graw-Hill;2001 • Paul D Chan MD , Christopher R Winkle MD current clinical strategies , Family medicine 2006 edition • Paul D Chan MD Margaret T Johnson MD treatment guidelines for medicine and primary care 2006 edition

  31. Thanks for your attention

More Related