Stemi 1
Download as PPTX, PDF1 like176 views
This case presentation discusses a 52-year-old male smoker who presented to the emergency department with chest pain and syncope. Initial workup found ST elevation on ECG consistent with an ST-segment elevation myocardial infarction (STEMI). The patient underwent coronary angiography which found significant coronary artery disease. He was started on guideline directed medical therapy and underwent coronary artery bypass grafting during his hospital stay. The case highlights the evaluation, management, and educational review of STEMI with a focus on reperfusion strategies, antiplatelet and anticoagulation therapy, and secondary prevention goals.
Stemi 1
- 1. CASE PRESENTATION Presented by: Dr. Abdullah Almazyad R1 Dr. Fatimah Alghamdi R3 Under supervision of :Dr. Abdullah Alkhudair
- 2. OBJECTIVES Case presentation History Physical Examination Differential diagnosis Investigation and management Patient hospital coarse Educational topic about disease Key point
- 3. CHIEF COMPLAINT • Chest pain for 15 minutes followed with a sudden syncope
- 4. Any Further Questions About Chest Pain
- 5. DIFFERENTIAL DIAGNOSES OF CHEST PAIN • MI, Angina, Myocarditis, And Pericarditis/Dressler’s Syndrome Cardiac • PE, Pneumothorax/Hemothorax, Tension Pneumothorax, Pneumonia, Empyema, Pulmonary • Neoplasm, Bronchiectasis, Pleuritis, And TB • Pulmonary • Esophageal: GERD, Esophageal Rupture, Spasm, Esophagitis, Ulceration, Achalasia, Neoplasm, And • Mallory-weiss Syndrome • Other Structures: PUD, Gastritis, Pancreatitis, And Biliary Colic • Gastrointestinal • Lymphoma, Thymoma • Mediastinal • Dissecting Aortic Aneurysm, Aortic Rupture • Vascular
- 6. HISTORY OF PRESENTING ILLNESS • Mr. N 52-year-old M. heavy smoker • Presented to ER with of typical chest pain • Pain was stared suddenly , in public place (the restaurant) while he was standing reached maximum 10/10 in few minutes. • Pain felt like heaviness in nature , radiating to the left shoulder and back , associated with diaphoresis and was aggravated by movement, • After 15-20 of heavy chest pain M.N felt dizzy due to intense pain , people tried to make him set and feel comfortable . • As a result EMS were called by one of the public and took patient to ER, no CPR or medication ware given to his way to ED. • Patient has positive history of similar episode few days ago while sleeping , was 5/10 in severity and relieved spontaneously within few minutes
- 8. PAST MEDICAL • Mr. N is not known to have any medical illness
- 9. PAST MEDICAL HISTORY No known cardiovascular risk factors except for smoking No history of Hypertension • No history of Hyperlipidaemia • No history of Myocardial infarction • No history of Chronic kidney disease • No history of Atrial fibrillation • No history of Stroke • No history of Peripheral vascular disease No history of Respiratory vascular disease No history of Gastrointestinal disease:
- 10. MEDICATION HISTORY AND ALLERGY • Patient never received : • Anticoagulants (e.g. pulmonary embolism) • Antiplatelets (e.g. coronary artery disease) • Statins (e.g. coronary artery disease) • Calcium channel blockers (e.g. hypertension) • ACE inhibitors (e.g. hypertension) • Antibiotics (e.g. pneumonia) • Colchicine (e.g. pericarditis) • No known allergy
- 11. PAST SURGICAL HISTORY • He once was admitted for appendectomy 18 years ago , there was no immediate or late complications • No history of blood Transfusion • No history of Car Accidents
- 12. FAMILY HISTORY • No family history of premature CAD • His father is 74 alive , he is diabetic and Hypertensive • His mother is 72 alive , she is hypertensive only • He has 1 brother and 3 sisters , all of them are medically free • No history of similar episode in the family • No history of cardiac disease • No family history of Familial Hypercholesteremia
- 13. SOCIAL • He is a smoker cigarettes, 250 packyears • Sedentary lifestyle • Works in food delivery since last year , originally was an employee in a marketing agency ,setting most of the time • Doesn’t follow a healthy diet, high saturated fatty diet • No history of Recreational drug use • No history of alcohol use/abuse
- 14. REVIEW OF SYSTEMS • Respiratory : • No chough , no SOB , no hemoptysis • Gastrointestinal : • No abdominal pain , no dysphagia , no diarrhea • Genitourinary : • No dysuria , no flank pain • Neurological : • No weakness , no dizziness , one episode of syncope for few minutes • Musculoskeletal : • No joint pain , no stiffness , no history of Trauma
- 15. • Hematology : • No Bruising , no history of ease of bleeding, no history of Autoimmune disease • Endocrine : • No history of cold intolerance or Polyuria
- 16. PHYSICAL EXAMINATION • Vital Signs ER • T : 36.5 BP : 153/87 Heart Rate : 96 RR: 20 SPo2 : 99% RA • General examination after admission • Conscious , Alert , Oriented to TPP , in distress due to chest pain • Diaphoretic • Not pale or Cyanotic • Connected to IV Cannula • BMI 45
- 17. HANDS AND HEENT • Hands : • No Nail Clubbing • No flapping Tremor • No Osler Nodes , Janeway lesions , or Splinter Hemorrhage • Eyes : • No pallor • No Jaundice • Nose : • No septal Deviation , No discharge • Ear : • No bulging of membrane or Perforation • Throat/Oral : • Poor Dental Hygiene , No central Cyanosis , No Erythema
- 18. CARDIOVASCULAR • Pulse : regular , no Radio-radial delay , no Radio-femoral delay • Inspection : • No scars , no prominent veins , no skin changes , no chest deformity , no visible pulsation • JVP not raise , no cannon wave • Palpation : • Apex beat in 5th intercostal space , midclavicular line • No palpable thrills , or Parasternal heaves • No Tenderness • Auscultation : • First and second heart sounds are audible throughout auscultatory area • No murmur , no S3 or S4? , no pericardial rub • Lower Limbs : no lower limbs edema
- 19. RESPIRATORY • Inspection : • Chest movement was symmetrical • Palpation : • Trachea was central ,equal chest expansion , no Subcutaneous emphysema • No palpable lymph nodes (anterior and posterior triangle , Supraclavicular , and axillary region) • Percussion : • Bilateral Resonant all over chest • Auscultation : • Vesicular Breathing equal bilaterally all over chest • No Wheezing or crackles
- 20. GASTROINTESTINAL • Inspection : • Abdomen is protuberant , symmetrical , Umbilicus is inverted • No visible hernia , no visible dilated veins , no visible masses • Palpation : • Soft and lax , no tenderness , no palpable masses • No Hepatomegaly or Splenomegaly • Percussion : • No shifting dullness • Liver span is approximately 10 cm • Auscultation : • Audible heart sounds , no renal bruit
- 21. MUSCULOSKELETAL • Joints : • No visible joint or bone deformities • No tenderness on movement or palpation • No decreased ROM , swelling or erythema
- 22. NEUROLOGICAL • GCS : 15/15 • Upper Limb • Sensory : intact for touch and pain • Normal power , tone and reflexes • Lower Limb : • Sensory : intact to touch and pian • Normal power , tone and reflexes
- 24. • Acute Coronary Syndrome • Pulmonary Embolism • Pneumothorax • Aortic Dissection • Acute Pericarditis
- 25. HOW WOULD YOU APPROACH MR. N IN EMERGENCY DEPARTMENT
- 26. ECG AT ADMISSION
- 27. LOCALIZATION OF MI ON ECG
- 28. STEMI ECG • ST elevation criteria • new ST elevation in two contiguous leads of >0.1 mV in all leads other than leads V2-V3 • for leads V2-V3: 0.2 mV in men 40 yr, 0.25 mV in men <40 yr, or 0.15 mV in women
- 29. “TYPICAL” SEQUENTIAL CHANGES OF EVOLVING MI • 1. hyperacute T waves (tall, symmetric T waves) in the leads facing the infarcted area, with or without ST elevation • 2. ST elevation (injury pattern) in the leads facing the infarcted area usually in the first hours post infarct • in acute posterior MI, there is ST depression in V1-V3 (reciprocal to ST elevation in the • posterior leads that are not recorded in the standard 12-lead ECG) hence get a 15- lead ECG • 3. significant Q waves: >40 msec or >1/3 of the total QRS amplitude and present in at least 2 • consecutive leads in the same territory (hours to days post-infarct) • Q waves of infarction may appear in the very early stages, with or without ST changes • non-Q wave infarction: there may be only ST or T
- 31. LABS AT ADMISSION 4/11/20 • WBC : 8.61 • HGB : 17.6 • PLT : 342 • PT : 12.5 • INR : 1.1 • PTT : 35.5 • Na : 139 • K : 3.8 • Cr : 84 • Troponin : 30 , is it enough? • on 5/11/20 it was 89000 • BNP : less then 10
- 32. LABS • AST : 71 • ALT : 73 • ALP : 38 • HDL : 0.71 • LDL 4.11 • Triglycerides :1.76 • Cholesterol : 4.92 • Bilirubin total : 26 • Bilirubin Direct : 7.2
- 33. CXR
- 34. ECHOCARDIOGRAPHY • LV normal in size, mildly reduced. LVEF =40% • large sized apical, septal, anteroseptal, and anterior wall motion abnormality with hypokinesis to akinesis of the segments • RV is normal in size and function. • Inadequate TR jet to assess RVSP. • No hemodynamically significant valve disease. • There is no pericardial effusion.
- 35. CORONARY ANGIOGRAPHY • Was Done • Insert vid
- 36. HOSPITAL COARSE • During admission patient was started on IHD Medications : • Received loading dose of Aspirin 300 mg PO , and Clopidogrel 180 mg PO • Then kept on : • Aspirin 100 mg PO OD • Clopidogrel 75 mg PO OD • Tirofiban infusion during and after cath for 18 hour • Atorvastatin 80 mg PO OD • Heparin Infusion until day of CABG • Bisoprolol 2.5 mg PO OD
- 37. EDUCATIONAL REVIEW FOR STEMI MANAGEMENT GOALS Preventing re-occlusion • Antiplatelet • antithrombosis Preventing mechanical complication • B-Blocker • ACEI • ARBs • Aldosterone antagonist Preventing recurrent Infarction • Statin • Cardiac rehab Preventing sudden cardiac death • AICD
- 38. EDUCATIONAL REVIEW FOR ACS MANAGEMENT AND COMPLICATION • ACS includes the spectrum of unstable angina (UA), NSTEMI, and STEMI; this distinction aids in providing the appropriate therapeutic intervention
- 39. 1. GENERAL MEASURES • 1. General Measures • ABCs: assess and correct hemodynamic status First • bed rest, cardiac monitoring, oxygen(if less 92) • nitroglycerin SL followed by IV • morphine IV
- 40. 2. ANTI-PLATELET AND ANTICOAGULATION THERAPY • NSTEMI • Ticagrelor, in addition to ASA or if ASA contraindicated, subcutaneous low molecular weight heparin or IV unfractionated heparin (UFH) • – LMWH preferable, except in renal failure or if CABG is planned within 24 h • clopidogrel used if patient ineligible for ticagrelor • If PCI is planned: ticagrelor or prasugrel and consider IV GP IIb/IIIa inhibitor (e.g. abciximab) • Clopidogrel used if patient ineligible for ticagrelor and prasugrel • Prasugel contraindicated in those with a history of stroke/TIA, and avoidance of or lower dose is recommended for those >75 year old or weighing under 60 kg (TRITON-TIMI 38) • ANTICOAGULATION OPTIONS DEPEND ON REPERFUSION STRATEGY: • Primary PCI: UFH during procedure; bivalirudin is a possible alternative • Thrombolysis: LMWH (enoxaparin) until discharge from hospital; can use UFH as alternative because of possible rescue PCI • no reperfusion: LMWH (enoxaparin) until discharge from
- 41. 3. B-BLOCKERS • STEMI: contraindications include signs of heart failure, low output states, risk of cardiogenic shock ,heart block, asthma or airway disease; initiate orally within 24 h of diagnosis when indicated • )
- 42. 4. INVASIVE STRATEGIES AND REPERFUSION OPTIONS STEMI After diagnosis of STEMI is made, do not wait for results of further investigations before implementing reperfusion therapy THROMBOLYSIS Goal is Door to Balloon <30 min preferred if patient presents 12 h of symptom onset, has contraindications to PCI, or PCI cannot be administered within 90 min Criteria for successful THROMBOLYSIS : • ST segment elevation resolution below half its initial magnitude • no chest pain • Reperfusion rhythms • PCI • Primary PCI: without prior thrombolytic therapy • Rescue PCI: following failed thrombolytic, improves mortality vs. thrombolysis with fewer intra-cranial hemorrhages and recurrent MIs
- 43. THANK YOU