Myocardial Infarction - Case Presentation and an Overview
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The document presents a clinical case study of a 65-year-old male patient, Muhammad Shareef, who was admitted with symptoms indicative of an acute myocardial infarction, compounded by a history of diabetes and coronary artery disease. Key findings included ST segment elevation on ECG, elevated cardiac biomarkers, and the initiation of thrombolytic therapy. The management plan also included lifestyle modifications and secondary prevention strategies, alongside a prognosis highlighting the importance of timely medical intervention.
Myocardial Infarction - Case Presentation and an Overview
- 1. Clinico-pathologicalconference 1st Myocardial infarctionPresentation by 1605- Abubakkar Raheel 1622- Haider Ali 1606- Ahmed Arsalan Final Year MBBS 27th February, 2015
- 2. Long Case • Muhammad Shareef, a 65 year old male patient from Abbottabad, known case of Diabetes since last 12 years and Coronary Artery Disease for the last 2 years presented in King Abdullah Teaching Hospital with the complaints of Chest pain and breathlessness for the last 6 hours. Patient had an episode of vomiting. He was conscious and well oriented. Overall health state was weak and meagre. Dept of Medicine Frontier Medical and Dental College
- 3. Dept of Medicine Frontier Medical and Dental College
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- 5. History of Patient • Name: Muhammad Shareef • Sex: Male • Age: 65 years • Marital Status: Married • Occupation: Retired Govt. servant • Address: Abbottabad • D.O.A: 20th February, 2015 • T.O.A: 9:30 am • M.O.A: OPD Dept of Medicine Frontier Medical and Dental College
- 6. Chief Complaints • Chest pain – 6 hrs • Shortness of Breath – 6 hrs • Vomiting - 5 hrs Dept of Medicine Frontier Medical and Dental College
- 7. History of Present illness • Known case of Diabetes - 12 yrs & Ischemic Heart Disease – 2 yrs • Chest pain started 6 hrs back • Sudden in onset • Retrosternal • Crushing in nature • Radiating to left arm, back and neck • Aggravated on exertion Dept of Medicine Frontier Medical and Dental College
- 8. History of Present illness • Shortness of breath – 6hrs • Sudden onset • present at rest • Vomiting – 5hrs • 2 episodes of vomiting • Vomitus was yellowish Dept of Medicine Frontier Medical and Dental College
- 9. History of Present illness Associated symptoms: • Moderate fever • Sweating • Dizziness • Patient was completely conscious • Palpitations Dept of Medicine Frontier Medical and Dental College
- 10. History of Present illness • Systemic Inquiry 1. General a. Reduced apetite b. Sleep disturbed c. Weakness 2. Respiration Cough, wheezing and hemoptysis not present Dept of Medicine Frontier Medical and Dental College
- 11. History of Present illness • Alimentary system: Nausea & Vomiting present • Urinary system: No significant history Dept of Medicine Frontier Medical and Dental College
- 12. History of Past illness • Past Medical History – Diabetes : 12 yrs – IHD : 2 yrs – HTN : Positive – TB : Negative – Asthma : Negative • Past Surgical History No significant past surgical history Dept of Medicine Frontier Medical and Dental College
- 13. Family History • Positive for IHD, HTN and DM • 2 brothers died of MI Dept of Medicine Frontier Medical and Dental College
- 14. Drug & treatment History • Patient was taking anti diabetics and anti hypertensive drugs • Drug compliance was poor • No other significant drug history Dept of Medicine Frontier Medical and Dental College
- 15. Personal History • Chronic Smoker • No history of drinking • Sedentary lifestyle Dept of Medicine Frontier Medical and Dental College
- 16. Socio-economic History • Satisfactory Dept of Medicine Frontier Medical and Dental College
- 17. History based Differential Diagnosis • Acute Myocardial Infarction • Unstable Angina • Pleurisy • Pericarditis • Pneumothorax • Pulmonary embolism • Reflex Esophagitis Dept of Medicine Frontier Medical and Dental College
- 18. General Physical Examination Patients general appearance • Pale and anxious Dept of Medicine Frontier Medical and Dental College
- 19. General Physical Examination • Vitals – B.P: 160/90mmHg in lying position – Pulse: 115 b/m, regular, tachycardia – Temp: 101 F – Resp: 30/m Dept of Medicine Frontier Medical and Dental College
- 20. General Physical Examination • No Clubbing, pallor, splinter hemorrhages koilonychias or leconichia • Mild tobacco staining observed • Xanthomas present on extensor surface of hands • Carotid pulse: thin • JVP: Not raised • Eyes: Anemia not present Dept of Medicine Frontier Medical and Dental College
- 21. General Physical Examination • Jaundice not present • Dental hygiene good • Carotid briut not audible • No abnormality on fundoscopy • No abnormality seen on thyroid examination • Lymph nodes not palpable • Pedal and Sacral edema absent • No other significant findings Dept of Medicine Frontier Medical and Dental College
- 22. Systemic Examination 1. CVS Systemic Examination a. Inspection: • No Chest deformity • No sternotomy or any other surgical scar b. Palpation: • Apex beat: Lateralized from mid clavicular line at 6th intercoastal spacece due to LVH Dept of Medicine Frontier Medical and Dental College
- 23. General Physical Examination • Heave: well sustained (at apex) • No left parasternal lift c. Auscultation: Mitral, Tricuspid, Aortic, Pulmonary Dept of Medicine Frontier Medical and Dental College
- 24. General Physical Examination • S1- Normal (Apex) • S2- Audible (Left sternal edge) • No added sounds • No murmurs Dept of Medicine Frontier Medical and Dental College
- 25. General Physical Examination c. GIT: • Liver not palpable • Spleen not palpable • Ascites not present d. Respiration: • Chest clear • No tracheal shift • No remarkable findings Dept of Medicine Frontier Medical and Dental College
- 26. General Physical Examination e. CNS: No remarkable findings Dept of Medicine Frontier Medical and Dental College
- 27. Examination based Differential Diagnosis • Myocardial Infarction • Unstable Angina Dept of Medicine Frontier Medical and Dental College
- 28. Investigations - ECG Dept of Medicine Frontier Medical and Dental College
- 29. Investigations ECG: Done within 25 mins of patient arrival Findings: • Rate: 78.9 • Rhythm: Sinus Rhythm Dept of Medicine Frontier Medical and Dental College
- 30. Investigations Leads showing ECG Changes: • V1 to V6, AvL • Changes include: • ST Segment Elevation • Q wave development • Loss of R Wave • T wave inversion Dept of Medicine Frontier Medical and Dental College
- 31. Investigations • Left Axis deviation seen by thumb rule on Lead 1 and AvF (For inferior wall MI, changes are seen in: Leads 2, 3 and AvF) Dept of Medicine Frontier Medical and Dental College
- 32. Investigations Cardiac biomarkers • Trop T raised • CK-MB raised Chest Xray • Cardiothoracic ratio increased showing LV Dilatation • Pulmonary edema not evident Dept of Medicine Frontier Medical and Dental College
- 33. Investigations – Xray Dept of Medicine Frontier Medical and Dental College
- 34. Investigations Other Blood Tests • ESR and CRP raised Echocardiography could not be done due to the non availablity of facility. Dept of Medicine Frontier Medical and Dental College
- 35. Investigations based Diagnosis Anterolateral ST Segment Elevation Myocardial Infarction with Left Axis Deviation Dept of Medicine Frontier Medical and Dental College
- 36. Management • Patient was immediately admitted in ICU. Within 10 mins, ECG was performed and based upon diagnosis, following treatment was given. • Oxygen + Cardiac rhythm monitoring Dept of Medicine Frontier Medical and Dental College
- 37. Management • Aspirin 300mg PO • (Therapy should be continued indefinitely if there are no side affects) • Clopidogrel 600mg PO followed by 150mg daily for 1 week and 75mg daily thereafter. • Streptokinase 1.5ml I.V in 100ml sol at 6ml/hr • Inj Morphine • Inj Metoclopromide I.V Stat Dept of Medicine Frontier Medical and Dental College
- 38. Late Management • Patient advised on the following: • Lifestyle Modification: • Lipid Lowering diet • Cessation of Smoking • Regular exercise Dept of Medicine Frontier Medical and Dental College
- 39. Late Management • Secondary Drug therapy: • Aspirin • B blocker • Ace Inhibitor/ARB • Statin • Additional therapy for DM and HTN Dept of Medicine Frontier Medical and Dental College
- 40. The patient was given Streptokinase (Thrombolysis) within 8 hours of his arrival. He is still in the ICU undergoing 24/7 observation and treatment. He was advised angiography due to the unavailability of the facility at the Hospital. We wish him a speedy recovery. Dept of Medicine Frontier Medical and Dental College
- 41. What is MI ? • Detection of rise and/or fall of cardiac biomarker values (preferably cardiac troponin) with atleast one of the following: • Symptoms of Ischemia • Significant ST segment-T wave changes or new LBBB • Development of pathological Q waves • Imaging evidence of new loss of viable myocardium • Angiographic identification of Intra coronary thrombus Dept of Medicine Frontier Medical and Dental College
- 42. Types of MI On the basis of ECG, there are two main types of MI • STEMI (major coronary artery complete obstruction) • Non-STEMI (Complete occlusion of a minor vessel or partial occlusion of a major coronary vessel Dept of Medicine Frontier Medical and Dental College
- 43. Arterial Supply of the Heart Dept of Medicine Frontier Medical and Dental College
- 44. Arterial Supply of the Heart Dept of Medicine Frontier Medical and Dental College
- 45. Arterial Supply of the Heart There are two major arteries which supply the heart • Left coronary artery • Right coronary artery 1. Left Coronary Artery: It is further divided into two main branches: LAD (I/V septum, Ant. Wall of LV and Apex) LCx (Lateral, Posterior and Inferior Walls) Dept of Medicine Frontier Medical and Dental College
- 46. Arterial Supply of the Heart 2. Right Coronary Artery It supplies RA, RV and inferio-posterior part of LV Branches include: PDA (supplies I/V septum inferior part) In 90% individuals PDA is a branch of RCA. (Right Dominant people) In 10% individuals PDA is a branch of LCA (Left Dominant) Dept of Medicine Frontier Medical and Dental College
- 47. Arterial Supply of SA & AV Node • SA Node: RCA in 60% individuals • AV Node: RCA in 90% individuals Clinical Significance: • Proximal RCA occlusion may result in Sinus Bradycardia and may also cause AV Nodal block • Abrupt occlusion of RCA may lead to infarction of inferior part of LV Dept of Medicine Frontier Medical and Dental College
- 48. Conducting system of Heart Dept of Medicine Frontier Medical and Dental College
- 49. Nerve Supply of Heart • Adrenergic Nerves from the Cervical Sympathetic chain supply atria and ventricles • Parasympathetic: Vagus nerve Dept of Medicine Frontier Medical and Dental College
- 50. Pathophysiology of MI Atheromatous plaque formation Interplaque haemorrhages Exposure of Subendothelial collagen fibers Formation of micro thrombi Full blown thrombus vasospasm Dept of Medicine Frontier Medical and Dental College
- 51. Pathophysiology of MI Dept of Medicine Frontier Medical and Dental College
- 52. Pathophysiology of MI Dept of Medicine Frontier Medical and Dental College
- 53. Pathophysiology of MI • LCA Occlusion: LAD occlusion (40-50) leads to Anterior wall infarction of LV Anterior portion of ventricular septum Apex LCx Occlusion 15-20% Lateral wall of LV Dept of Medicine Frontier Medical and Dental College
- 54. Pathophysiology of MI RCA Occlusion (30-40%) RCA occlusion leads to infarction of • Posterior wall of RV • Inferior wall of LV • Posterior 1/3rd of I/V septum Dept of Medicine Frontier Medical and Dental College
- 55. Clinical features Symptoms: • Pain: Crushing, retrosternal chest pain radiating to back, left arm, neck or jaw • Anxiety and fear of impending death • Nausea and Vomiting • Breathlessness • Diaphoresis Dept of Medicine Frontier Medical and Dental College
- 56. Clinical features – Pain Areas Dept of Medicine Frontier Medical and Dental College
- 57. Clinical features • Signs Sympathetic activation: - pallor - sweating - tachycardia Vagal activation: -bradycardia Dept of Medicine Frontier Medical and Dental College
- 58. Clinical features vomiting • Signs of impaired myocardial function: Hypotention Narrow pulse pressure JVP may be raised Dept of Medicine Frontier Medical and Dental College
- 59. Clinical features 3rd heart sound Quiet 1st heart sound Diffuse apical impulse Lung crepitations Dept of Medicine Frontier Medical and Dental College
- 60. Clinical features • Signs of tissue damage fever • Signs of complications e.g Mitral regurgitation, pericarditis etc Dept of Medicine Frontier Medical and Dental College
- 61. Clinical features • Silent MI diabetic patients Older individuals Dept of Medicine Frontier Medical and Dental College
- 62. Investigations • ECG • Cardiac biomarkers • Chest X-Ray • Echocardiography • ESR & CRP • Angiography Dept of Medicine Frontier Medical and Dental College
- 63. Investigations • ECG It is central to confirming the diagnosis but may be difficult to interpret if there is bundle branch block or previous MI. so repeated ECGs are very important. Dept of Medicine Frontier Medical and Dental College
- 64. Investigations – Normal ECG Dept of Medicine Frontier Medical and Dental College
- 65. Investigations – Normal ECG Dept of Medicine Frontier Medical and Dental College
- 66. Investigations - ECG Earliest changes are seen in ST-segment 1. STEMI • ST-segment elevation • progressive loss of R wave . • Development of Q wave . • Resolution of ST-segment • T-wave inversion Dept of Medicine Frontier Medical and Dental College
- 67. Investigations - ECG 2. NSTEMI • St-segment depression • T-wave changes • Loss of R-wave • Absence of Q-wave Dept of Medicine Frontier Medical and Dental College
- 68. Investigations – ECG - STEMI Dept of Medicine Frontier Medical and Dental College
- 69. Investigations - ECG Significance of chest leads Antero-septal infarct v1 ,v2,v3,v4 Antero-lateral v4,v5,v6 and AVL and 1 Dept of Medicine Frontier Medical and Dental College
- 70. Investigations - ECG Inferior infarction leads II , III and AvF Posterior wall infarction doesn’t cause ST elevation or Q-waves in the standad leads but can be diagnosed by the reciprocal changes that is st depression and a tall R-wave and leads V1-V4. Dept of Medicine Frontier Medical and Dental College
- 71. Cardiac Biomarkers 1. Troponins 2. Creatinine kinases 3. LDH 4. AST 5. Myoglobins 6. Most specific are troponins and CK-MB Dept of Medicine Frontier Medical and Dental College
- 72. Cardiac Biomarkers 1. CK-MB Rises in 4-6 hours and peaks a 12 hours and falls to normal within 48-72 hours . It is very important. For diagnosis of recurrent MI’s. 2. Troponins: Trop-T and trop-I are gold standards for diagnosis of MI, Troponins rise in 4 to 6 hours and remains elevated for 2 weeks Dept of Medicine Frontier Medical and Dental College
- 73. Investigations- Chest Xray • Chest Xray to determine cardiomegaly and pulmonary edema Dept of Medicine Frontier Medical and Dental College
- 74. Investigations - Echocardiography • Useful for assessing ventricular function and determining complications Eg. Mural thrombus, cardiac rupture , VSD and pericardial effusion etc Dept of Medicine Frontier Medical and Dental College
- 75. Investigations - Other blood tests 1. ESR raised 2. Leucocytosis 3. CRP raised Dept of Medicine Frontier Medical and Dental College
- 76. Management Dept of Medicine Frontier Medical and Dental College
- 77. Management Dept of Medicine Frontier Medical and Dental College
- 78. Drugs used in treatment of MI 1. Analgesics - Opiates: Morphine Sulphate dimorphine 2. Anti-emetics: metoclopromide 3. Anti-thrombotic drugs a. Anti platelets: Aspirin - Clopidogrel - Ticagrelor - Gycoprotien 2b and 3a receptor antagonists: Abciximab Dept of Medicine Frontier Medical and Dental College
- 79. Drugs used in treatment of MI b. Anticoagulants : – LMW Heparin, HMW Heparin, pentasaccharide - fondaparinux – Warfarin Dept of Medicine Frontier Medical and Dental College
- 80. Drugs used in treatment of MI 4. Anti anginal drugs - Nitrates: GTN, isosorbide dinitrate - B blockers: metoprolol and atenolol 5. Dihydropyridine CCBs: - Nifedipine, amlodipine 6. Thrombolytics: - Alteplase, streptokinase, retiplase, tenecteplase Dept of Medicine Frontier Medical and Dental College
- 81. Invasive modalities used in the treatment of MI • PCI (Percutaneous Intervention) • CABG (Coronary Artery Bypass graft) Surgery Dept of Medicine Frontier Medical and Dental College
- 82. Late Management of MI Lifestyle modifications Diet Cessation of smoking Weight control Reguar exercise Dept of Medicine Frontier Medical and Dental College
- 83. Late Management of MI- Sec prevention • Anti platelet therapy • B blockers • Ace inhibitors • Statins • Additional therapy for diabetes and HTN control • Mineralocorticoid receptor antagonist • Devices: Implantable Cardiac Defibrillators Dept of Medicine Frontier Medical and Dental College
- 84. Complications • Arrythmias • Bradycardia • Acute Circulatory failure • Pericarditis Dept of Medicine Frontier Medical and Dental College
- 85. Complications - Mechanical • Rupture of papillary muscle • Rupture of I/V septum • Rupture of ventricle which can lead to fatal cardiac temponade • Embolism • Impaired ventricular function, remodeling and ventricular aneurysm Dept of Medicine Frontier Medical and Dental College
- 86. Prognosis • If medical care is not provided, death occurs in almost 1/4th of the cases. Half of the death occurs within 24nhours of the onset of symptoms and about 40% of all affected patients die within the first month. • Patients who reach the hospital and survive have much better prognosis with a 28 day survival of more than 85%. The prognosis of anterior infarcts is worse as compared to inferior infarcts. Dept of Medicine Frontier Medical and Dental College
- 87. Prognosis OF THOSE WHO SURVIVE AN ACUTE ATTACK, MORE THAN 80% LIVE FOR A FURTHER YEAR. ABOUT 75% FOR 5 YEARS. 50% FOR 10 YEARS & 25% FOR 20 YEARS. Dept of Medicine Frontier Medical and Dental College
- 88. Thankyou everyone Dept of Medicine Frontier Medical and Dental Collegev