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