case presentation Done by :AHDAB KHAYAT

1

case presentation Done by :AHDAB KHAYAT

22

Myocardial infarctionMyocardial infarction

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

33

EpidemiologyEpidemiology

1.5 million Americans have an AMI each 1.5 million Americans have an AMI each year year

Mortality ranges from 10 to 15 % during Mortality ranges from 10 to 15 % during the first year , decrease to 3.5 % per year the first year , decrease to 3.5 % per year

44

PathophysiologyPathophysiology

AtherosclerosisAtherosclerosis thrombosis thrombosis Myocardial necrosisMyocardial necrosis

55

EtiologyEtiology

Coronary thrombosis due to ruptured Coronary thrombosis due to ruptured plaque including platelet aggregationplaque including platelet aggregation

Coronary artery spasmCoronary artery spasm Embolic infarctionEmbolic infarction Cocaine induced vasospasm Cocaine induced vasospasm

66

Clinical presentationClinical presentation

Acute chest pain or discomfortAcute chest pain or discomfort

Radiated to an upper extremityRadiated to an upper extremity

Associated with diaphoresis , nausea and Associated with diaphoresis , nausea and vomitingvomiting

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Chest painChest pain

Gradual in onsetGradual in onset Provoked by an activityProvoked by an activity Not change by position or respirationNot change by position or respiration Difficult to localizeDifficult to localize Last longer than 30 minLast longer than 30 min

88

Risk factorRisk factor

Family history of CHDFamily history of CHD age age sex sex DMDM hypertensionhypertension hyperlipidemia hyperlipidemia cigarette smokingcigarette smoking cocaine use cocaine use

99

DiagnosisDiagnosis

ECGECG Cardiac enzyme monitoringCardiac enzyme monitoring

-CK MB : 3-6hr, peak12-24hr-CK MB : 3-6hr, peak12-24hr

normal 36-48hrnormal 36-48hr

-LDH : 24-48hr, peak 3-6d-LDH : 24-48hr, peak 3-6d

-Troponins : late marker -Troponins : late marker

1010

complicationcomplication

CHFCHF Cardiogenic shockCardiogenic shock Myocardial ruptureMyocardial rupture DysrhythmiaDysrhythmia Deep venous thrombosisDeep venous thrombosis Pulmonary embolism Pulmonary embolism

1111

Goals of therapyGoals of therapy

Limit extension of myocardial necrosisLimit extension of myocardial necrosis Prevent reinfarctionPrevent reinfarction Control complications Control complications

-pain -hyper or hypotension -pain -hyper or hypotension

-CHF -ventricular irritability-CHF -ventricular irritability

1212

Nonpharmacologic therapyNonpharmacologic therapy

Bed rest during first 24hr after acute Bed rest during first 24hr after acute eventeventdecrease myocardial Odecrease myocardial O22 consumption prevent extension of consumption prevent extension of infarction during healinginfarction during healing

Start low saturated fat and cholesterol dietStart low saturated fat and cholesterol diet Stop smokingStop smoking

1313

Treatment planTreatment plan

OO2 2 2-4 L/min2-4 L/min Is administered unless the patient has Is administered unless the patient has

sever chronic obstructive pulmonary sever chronic obstructive pulmonary disease disease

ASA antiplatelet effect ASA antiplatelet effect 325 mg po then 162mg po325 mg po then 162mg poor plavix 75 mg po (ASA allergy)or plavix 75 mg po (ASA allergy)or ASA 325 mg then 81-162 mg OD + plavix or ASA 325 mg then 81-162 mg OD + plavix

300 mg then 75mg po OD300 mg then 75mg po OD

1414

Nitrates to relieve ischemic pain Nitrates to relieve ischemic pain Nitroglycerin infusion 10mcg/min syst>90Nitroglycerin infusion 10mcg/min syst>90

or SL 0.4 mg q5min up to 3 tabor SL 0.4 mg q5min up to 3 tab

or spray 0.4 mg/aerosol q5min BIDor spray 0.4 mg/aerosol q5min BID

1515

Heparin as adjunctive therapy to Heparin as adjunctive therapy to prevent rethrombosis prevent rethrombosis

60U/kg IV push then 15U/kg/hr IV infusion 60U/kg IV push then 15U/kg/hr IV infusion (monitor APTT )(monitor APTT )

Glycoprotein IIb/IIIa blocker in high risk Glycoprotein IIb/IIIa blocker in high risk patient patient

Eptifibatide 180mcg/kg IVP then Eptifibatide 180mcg/kg IVP then 2mcg/kg/min for 48-72hr2mcg/kg/min for 48-72hr

1616

B blocker slow the heart B blocker slow the heart

-atenolol 5mg Iv then 50-100mg po-atenolol 5mg Iv then 50-100mg po

-esmolol 500mcg/kg Iv over min then -esmolol 500mcg/kg Iv over min then 50mcg/kg/min Iv infusion ..HR>6050mcg/kg/min Iv infusion ..HR>60

1717

ACEIACEI

prevent a build up of fluid by interfering prevent a build up of fluid by interfering with the enzyme 'angiotensin' which is with the enzyme 'angiotensin' which is involved in regulating body fluid involved in regulating body fluid

lisinopril 2.5-5 mg increase to 10-20mglisinopril 2.5-5 mg increase to 10-20mg

benzapril 10mgbenzapril 10mg

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Long acting nitrate Long acting nitrate

- nitroglycerin patch- nitroglycerin patch

-isosorbide dinitrate 10-60mg po TID-isosorbide dinitrate 10-60mg po TID

Or isosorbid mononitrate 30-60 mg Or isosorbid mononitrate 30-60 mg

1919

StatinStatin

-atorvastatin 10mg q HS-atorvastatin 10mg q HS

-simvastatin 40 mg q HS-simvastatin 40 mg q HS

2020

Symptomatic Symptomatic -morphine 2-4mg Iv prn chest pain-morphine 2-4mg Iv prn chest pain -acetamenophin 325-650mg q4-6hr prn -acetamenophin 325-650mg q4-6hr prn

headacheheadache -lorazepam 1-2 mg TIDprn anxiety -lorazepam 1-2 mg TIDprn anxiety -zolpidem 5-10 mg qhs prn insomnia-zolpidem 5-10 mg qhs prn insomnia -docusate 100mg BID-docusate 100mg BID -famotidine 20mg Iv BID -famotidine 20mg Iv BID

2121

Cardiac catheterizationCardiac catheterization

An early invasive approach in patient at An early invasive approach in patient at intermediate to high risk intermediate to high risk

and those in whom conservative and those in whom conservative management has failed management has failed

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The patient’s case

J.Z 50Y Dr. Nabil AL Ama

2323

J . Z is a 50 years old male admitted at J . Z is a 50 years old male admitted at 30/9 under Dr Nabil Al Ama diagnosed 30/9 under Dr Nabil Al Ama diagnosed with MIwith MI

He is married , non smoker He is married , non smoker No family history of IHDNo family history of IHD

2424

PMH PMH ::

history… DM , HTN , unstable anginahistory… DM , HTN , unstable angina

dyslipidemia dyslipidemia

3 days back discharge..unstable angina 3 days back discharge..unstable angina

plavix, ASA, capotin, atenolol, isordilplavix, ASA, capotin, atenolol, isordil

neurobion, amlor, amaryl, lactuloseneurobion, amlor, amaryl, lactulose

zocor. zocor.

2525

CASECASEERER 30/9/2006 30/9/2006

CC CC : :

sever chest pain sever chest pain

BPBP PP RRRR

142/65142/65 6767 2222

isordilisordil 5mg SL5mg SL

OO22 3L/min3L/min

2626

datedate drugdrug groupgroup dosedose monitormonitor

30/930/9 AmarylAmaryl

glimepirideglimepiride

sulphonylsulphonylureaurea

3g po 3g po BIDBID

glucoseglucose

metforminmetformin biguanidebiguanide 1g po 1g po BIDBID

glucoseglucose

ZocorZocor

simvastatinsimvastatin

statinstatin 40mg 40mg po ODpo OD

Lipid profile Lipid profile

amlodipineamlodipine Ca Ca blockerblocker

10mg 10mg po ODpo OD

BPBP

Treatment plan

Max Max

4mg/d may 4mg/d may 6mg/d6mg/d

2g/d2g/d

80mg/d80mg/d

10mg/d10mg/d

2727


30/930/9 atenololatenolol B blockerB blocker 50 mg po 50 mg po BIDBID

BPBP

captoprilcaptopril ACEIACEI 25mg po 25mg po TIDTID

BPBP

neurobionneurobion vit B vit B complex complex

1 tab BID1 tab BID

ASAASA antiplatletantiplatlet 81mg po 81mg po ODOD

PTPT

maxmax

200mg/d200mg/d

150mg/d150mg/d

4g/d4g/d

2828

datedate drugdrug groupgroup dosedose monitormonitor maxmax

30/930/9 plavixplavix antiplatletantiplatlet 75mg po 75mg po ODOD

PTPT 300mg300mg

75mg75mg

statstat heparinheparin anticoagulanticoagulantant

5000u5000u

bolusbolus

APTTAPTT

statstat heparinheparin anticoagulanticoagulantant

1000 u/hr1000 u/hr APTTAPTT

PRNPRN paracetaparacetamolmol

analgesicanalgesic 1 g1 g

1/101/10 heparinheparin anticoagulanticoagulantant

1300u/hr1300u/hr APTTAPTT

24.624.6

2929


2/102/10 lactuloselactulose laxativelaxative 20cc 20cc TIDTID

wtwt

isordilisordil Vasodilator Vasodilator 10mg 10mg po TIDpo TID

Chest painChest pain

pantoprazolepantoprazole Proton pumpProton pump 40mg 40mg ODOD

maxmax

240mg/d240mg/d

ElderlyElderly

40mg/d40mg/d

3030


2/102/10 heparinheparin anticoagulantanticoagulant 1400u/hr1400u/hr APTTAPTT

5454

2/102/10

PRNPRN

isordilisordil vasodilatorvasodilator 5mg sl5mg sl

3/103/10 ASAASA antiplatletantiplatlet 81mg BID81mg BID PTPT

3/103/10 heparinheparin anticoagulantanticoagulant 1700u/hr1700u/hr APTTAPTT

56.756.7

4/104/10 vastrelvastrel vasodilatorvasodilator 35mg BID35mg BID

4/104/10

prnprn

Voltarin gelVoltarin gel locallocal Muscle painMuscle pain

3131

datedate drugdrug groupgroup dosedose monitormonitor maxmax5/105/10 cefuroximecefuroxime CephaloCephalo

22ndnd

250mg 250mg po BIDpo BID

cultureculture

metocloprmetoclopramideamide

antiemeticantiemetic 10mg po 10mg po BIDBID

dehydratiodehydrationn

500mcg500mcg

/kg/kg

heparinheparin anticoagulanticoagulantant

5000u sc5000u sc APTTAPTT

6/106/10 fusidinfusidin Fusidic Fusidic acid Abacid Ab

Local Rt Local Rt armarm

Skin Skin infectioninfection

augmentinaugmentin penicillinpenicillin 1.2g IV1.2g IV cultureculture

7/107/10 mycostatinmycostatin antifungalantifungal Oral drop Oral drop TIDTID

Mouth Mouth infectioninfection

lactuloselactulose laxativelaxative 20cc HS20cc HS wtwt

ceftriaxoneceftriaxone CephaloCephalo

3rd3rd

1g IV BID1g IV BID cultureculture

8/108/10 ciprobayciprobay quinolonequinolone 500mg po 500mg po BIDBID

cultureculture

3232

Lap resultLap result30/930/9 1/101/10 2/102/10 3/103/10 4/104/10 6/106/10 8/108/10

BPBP mmHgmmHg

158/60158/60 140/80140/80 160/90160/90 140/80140/80 140/80140/80 110/60110/60 130/7130/700

PTPTsecsec

1212 11.211.2 1212 12.312.3 11.911.9 ----------

APTTAPTTsecsec

29.429.4 24.624.6 5454 56.756.7 6060 ----------

GLU GLU mmolemmole

13.113.1 12.212.2

F 8.7F 8.7

4.24.2

8.78.7

4.14.1 5.75.7

14.114.1

8.88.8

ckMBckMBIu/lIu/l

5.45.4 3.43.4 33 33 3.33.3 1.31.3 2.92.9

LDHLDHu/lu/l

141141 113113 190190 190190 233233 ---------- 102102

TROTROP P mic/lmic/l

0.370.37 0.40.4 0.170.17 0.170.17 0.170.17 0.120.12 0.080.08

11-1411-14

29-4029-40

45-7545-75

3.6-7.63.6-7.6

0-3.60-3.6

100-190100-190

0-0.050-0.05

3333

30/930/9 1/101/10 2/102/10 3/103/10 4/104/10 6/106/10 7/107/10 8/108/10

NaNa mmole/lmmole/l

142142 143143 -------- -------- -------- 133133

K K mmole/lmmole/l

3.83.8 44 -------- -------- -------- 3.73.7

HDLHDL 0.680.68 -------- -------- -------- ------------

LDLLDL 22 -------- -------- -------- --------------

BUNBUNMmole/lMmole/l

3.73.7 4.34.3 -------- -------- -------- 6.96.9

CreatCreatMicmol/lMicmol/l

9292 7878 -------- -------- -------- 104104

136-145136-145

3.5-5.13.5-5.1

0.9-1.550.9-1.55

0-3.570-3.57

2.5-6.42.5-6.4

53-11553-115

30-6530-65 ALTALT 7474 7373 ---------- -------- -------- ----------

15-3715-37 ASTASTu/lu/l

4141 3939 3535 3535 6969 3838

3434

Drug interactionDrug interaction

Hypoglycemic effect enhanced by ACEIHypoglycemic effect enhanced by ACEI Hypoglycemic effect enhanced by NSAIDsHypoglycemic effect enhanced by NSAIDs B blocker mask sign of hypoglycemiaB blocker mask sign of hypoglycemia ACEI,B blocker,Ca blocker and nitrate ACEI,B blocker,Ca blocker and nitrate

enhance hypotensive effectenhance hypotensive effect Plavix enhance bleeding risk with ASA and Plavix enhance bleeding risk with ASA and

heparinheparin

3535

recommendationrecommendation

Close monitoring of BP and glucose levelClose monitoring of BP and glucose level Start diabetic diet Start diabetic diet Replace oral hypoglycemic by insulin Replace oral hypoglycemic by insulin

glucose level not controlled glucose level not controlled Decrease dose of pantoprazole to 20mg/d Decrease dose of pantoprazole to 20mg/d

( prophylaxis of NSAIDs )( prophylaxis of NSAIDs ) Replace lactulose by bisacodyl 5-10mg at Replace lactulose by bisacodyl 5-10mg at

night or docusate 100mg BID….DMnight or docusate 100mg BID….DM WT reduction for cardiac catheterization WT reduction for cardiac catheterization

3636

ReferencesReferences

Christopher T, Alexander M, Sukhdev C: The hand-on Christopher T, Alexander M, Sukhdev C: The hand-on guide to clinical pharmacology. 2nd ed.USA: Blackwell; guide to clinical pharmacology. 2nd ed.USA: Blackwell; 20052005

Parveen K, Michael C: Clinical medicine.5th ed.UK: Parveen K, Michael C: Clinical medicine.5th ed.UK: W.B.Saunders; 2002:701-832W.B.Saunders; 2002:701-832

Seymour K, Eli DE: Clinician’s handbook of prescription Seymour K, Eli DE: Clinician’s handbook of prescription drugs. International ed.USA:Mc-Graw-Hill;2001drugs. International ed.USA:Mc-Graw-Hill;2001

Paul D Chan MD , Christopher R Winkle MD current Paul D Chan MD , Christopher R Winkle MD current clinical strategies , Family medicine 2006 editionclinical strategies , Family medicine 2006 edition

Paul D Chan MD Margaret T Johnson MD treatment Paul D Chan MD Margaret T Johnson MD treatment guidelines for medicine and primary care 2006 edition guidelines for medicine and primary care 2006 edition

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case presentation Done by :AHDAB KHAYAT