html5-img
1 / 44

Acute coronary syndrome

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.

hertz
Télécharger la présentation

Acute coronary syndrome

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. Acute coronary syndrome Camille Ann L. Asuncion Case Presentation TMC IM-ER

  2. 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)

  3. Chief Complaint • Chest Pain

  4. 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: IsorbideMononitrate (Imdur) 30 mg tab

  5. History of Present Illness 3 hours PTC Recurrence of chest pain sudden onset, substernal, nonradiating occurring at rest 20 minutes duration 10/10 in severity with associated diaphoresis Headache diffuse, nonpulsating, nonradiating 5/10 in severity Meds: IsorbideMononitrate (Imdur) 30 mg tab

  6. History of Present Illness Persistence of symptoms Rushed to TMC ER

  7. 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, EthambutolHCl 275 mg (Quadtab) 3 tablets before breakfast, OD

  8. Past medical history • No Hypertension • No asthma • No pneumonia • No allergies • No previous surgeries

  9. Family history • (+) Diabetes Mellitus • mother • (+) asthma • paternal side • No Hypertension • No Pneumonia • No TB • No Heart disease

  10. 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

  11. Review of Systems • Constitutional: no weight loss, no weakness, no fatigue • HEENT: no dizziness, no blurring of vision, no nosebleeds, no gum bleeding, no enlarged lymph nodes • Respiratory: cough, no dyspnea, no hemoptysis, no wheezing • Cardiovascular: no easy fatigability, no orthopnea, no syncope • Gastrointestinal: no nausea/vomiting, no change in bowel habits • Genitourinary: no dysuria, polyuria, no hematuria, no frequency • CNS: no seizure, no tremor • Muskuloskeletal: no muscle/joint pains, no joint swelling • Endocrine: no cold/heat intolerance

  12. 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

  13. 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: adynamicprecordium, 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.)

  14. 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

  15. 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

  16. Differential diagnoses • ACS • STEMI • NSTEMI • UNSTABLE ANGINA

  17. Initial Diagnosis • Acute Coronary Syndrome • PTB 3 • DM II

  18. Er diagnostics • ECG

  19. Er diagnostics • ECG: possible inferior infarct • CBC • Cardiac Enzymes Hgb 110 Neut 0.68 Hct 0.33 Lymph 0.22 WBC 7.3 Mono 0.06 PC 304 Eosino 0.04 Hypochromic 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) • Trop I (-) • CK-MB 14.54 (0-25) • CK-MM 11.83 (24-179) • CK-Total 26.37 (24-204)

  20. 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

  21. 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

  22. Final Diagnosis • Unstable Angina • PTB 3 • DM II

  23. Case discussion

  24. 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

  25. 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 partialthickness of the heart muscle Vs. NSTEMI : severity of ischemia to cause sufficient myocardial damage; Cardiac marker (-)

  26. 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

  27. 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

  28. diagnosis • “high likelihood patient” • Established CAD by angiography • History of CABG or PCI • History of MI, CHF • Multiple CAD risk factors

  29. diagnosis

  30. 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

  31. pathophysiology 4. Unstable Fibrous Plaque • Lesion expansion  apoptosis, necrosis 3. Plaque Rupture with thrombus • Clot overwhelms fibrinolytic mechanisms  Rupture of fibrous cap  thrombosis

  32. pathophysiology

  33. pathophysiology

  34. 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

  35. 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

  36. Diagnostics • Cardiac Markers • Troponin I (within 3 hours  ~1 week) • Sensitive and specific • CK-MB • CK-MM • CK-Total

  37. 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

  38. treatment

  39. 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

  40. Prognosis

  41. 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

  42. Public health and Prevention • Promote Healthy Lifestyle • DIET modification • Smoking cessation • Diabetes management • Hypertension control

  43. Acute coronary syndrome Camille Ann L. Asuncion Case Presentation TMC IM-ER

More Related