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Presentor: John Hommer E. Dy M.D. Moderator: Joy Marchadesch M.

Presenting a case of a 66 year old female

presented with chest pain

To discuss Acute Coronary Syndrome its

etiology, pathogenesis, diagnosis, treatment and prevention

B.R, Female, 66yo widowed Roman Catholic

Housewife
From Legazpi City

Chest Pain

1 week

On and off retro sternal sharp chest pain Easy fatigability Chest tightness Diaphoreses Difficulty of breathing Vomiting

Few hours

admission

General: No recent weight change, (+) body

weakness, (-) fever

Skin: No rashes or pruritus

HEENT: No headache, no blurring of vision, no

difficulty of swallowing

Respiratory: No cough Cardiovascular: no palpitations Extremities: Bipedal edema

HPN unrecalled duration, unrecalled medication

with poor compliance Non-DM No previous Hospitalization No history of any surgical operation No allergy to food and drugs

(+) HPN mother, siblings

(-) DM
(-) Cancer (-) bronchial asthma

(-) heart disease

Non - smoker

Non- alcoholic drinker

General Survey:
Conscious Coherent Diaphoretic In cardio-respiratory distress

Vital Signs

BP: 70/50 mmHg CR: 52 bpm RR: 25 cpm Temp: 36oC Weight: 51kg Height: 54 BMI: 23 O2 sat : 97-98%

Skin: Afebrile Good skin turgor Cold to touch

HEENT: Pink palpebral conjunctiva anicteric sclerae no naso-aural discharge, no tonsillo-pharyngeal congestion

Neck:

No cervical lymphadenopathies
no mass (+) neck vein engorgement

Chest/Lungs:
Symmetrical chest expansion (+) retractions subcostal

Bibasal crackles

Heart: Adynamic precordium, Apex beat at 5th left ICS, AAL, Bradycardic, regular rhythm, no murmur

Abdomen: flabby Normoactive bowel sounds 8 cm liver span midclavicular line and 5 cm midsternal (+) epigastric tenderness no guarding and rigidity

Extrenities:

(+) Bipedal edema grade 1, full and equal pulses

66year old female

Difficulty of breathing
Chest pain Diaphoresis

Epigastric pain
Engorged neck vein Bibasal crackles

Bipedal edema

Acute Coronary Syndrome, CHF, FC II

Aortic dissection Pneumothorax

GERD
Pulmonary Embolism

DISEASE ENTITY Aortic dissection

RULE - IN Chest pain

RULE-OUT Tearing pain Murmur Bruits Unequal pulses Trop-I:negatiive Diminished breath sounds over hemithorax Trop-I: Negative

Pneumothorax

Chest pain Dypnea

GERD
Pulmonary embolism

Retrosternal chest pain

Nausea nd vomiting Trop-I Negative

On Admission: Low salt and low fat diet Diagnostic:


12 Lead ECG
Troponin I CXR-PA Na, K, Ca, Mg Lipid profile, ALT and Creatinine CBC with PC Urinalysis

IVF w/ D5W
Dopamine drip

Chest Xray: Markedly enlarged cardiac shadow with pulmonary

congestion.Calcified Aortic knob.

WBC
Hemoglobin
Hematocrit Platelet count Neutrophils 41

8.1
114
0.38 145 59 26

Medication:
Fondaparinux 2.5 mg sq, OD
ASA 80 mg 4 tabs Stat chewed then 1 tab OD Clopidogrel 75mg 4 tabs Stat chewed then 1 tab OD Atorvastatin 80mg 1 tab @ HS

Lactulose 30cc @ HS

2nd Hospital day


S> Decrease chest pain, (+) Bipedal edema O> BP: 90/50 - 120/70 CR: 84 bpm RR: 18cpm

A> Acute Coronary Syndrome, NSTEMI vs UA, CHF,

FC II
P> 2D Echo once stable Repeat 12-L ECG Start Trimetazidine 35mg/tab, BID Fondaparinux 2,5 mg SQ OD Furosemide 20 mg IV q8 provided SBP >100mmhg Spironolactone 25 mg tab, OD Lanzoprazole 30 mg tab, OD continue Dopamine drip

Labs: Trop I: Positive

Chole: 5.3 mmol/L Trigly: 1.63 mmol/L N HDL: 0.9 mmol/L LDL: 3.67 mmol/L VLDL: 0.7 mmol/L Chol/dHD: 6.18 Urea: 5.4 mmol/L Crea: 101 umol/L K: 4.1 mmol/L Calcium: 2.54 mmol/L ALT: <3 U/L

3rd

Hospital day

S> (-) Chest pain , (-) DOB, (+) bipedal edema,

grade 1 O> BP: 95/50- 115/64 mmhg CR:80 bpm RR:22 cpm A> Acute Coronary Syndrome, NSTEMI, in SR, CHF, FC II P> Continue Dopa drip

Labs:
Color Transparency Reaction Specific gravity Yellow Sl. turbid 6 1.020

Pus cells
RBC Epithelial cells Bacteria Albumin Sugar

1-2/hpf
0-1/hpf Few Few negative negative

4th Hospital day:


S> BP: 90/50 mmhg CR: 60 bpm RR: 25 cpm O> (-) chest pain, , (-) DOB, bipedal edema

A> Acute Coronary Syndrome, NSTEMI, in SR,

CHF, FC II P> Repeat 12-L ECG


Furosemide @ 20 mg IV q 8hrs

Magnesium Na K

0.68 N 131 N 4.03 N

5th Hospital day: S> BP: 140/80 mmhg CR: 65 bpm RR: 23 cpm O> (-) chest pain, , (-) DOB, bipedal edema A> Atherosclerotic heart disease, Acute Coronary Syndrome, NSTEMI, in SR, CHF, FC II P> Continue medication May transfer to cardio ward shift furosemide IV to 20mg/tab 12-L ECG

7th Hospital day


A> Acute Coronary Syndrome, NSTEMI, in SR, CHF, FC II P>Discharged improved
THM:
Trimetazedine 350mg, BID Spironolactone 25mg/tab, tab OD ASA 80mg/tab, OD Clopidogrel 75mg/tab, OD Atorvastatin 80mg/tab, OD HS Lansoprazole: 300 mg OD x 7 days Lactulose 30cc OD @ HS

IHD

CAD (stable angina)

ACS

Unstable Angina (No ST Elevation ACS)

No ST Elevation

ST Elevation

NSTEMI (Trop-I: +)

STEMI

Imbalance between myocardial oxygen supply and

demand.
Or by increase in myocardial oxygen demand

superimposed on an atherosclerotic plaque.

1. Plaque rupture or erosion w/ superimposed

nonocclusive thrombus.
2. Dynamic Obstruction 3. Progressive mechanical obstruction 4. 2ndry UA related to increased myocardial oxygen

demand and/or decreases supply

Clinical History/P.E.

Echocardiogram: ST-segment depression > 0.5 mm (0.5 mv)

in two or more contigous leads.


Biochemical markers: rise in Troponins occurs after 3 to 4

hours. And may persist elevated up to 2 weeks.


Echocardiography
Imaging of the coronary anatomy

Chest pain

Dyspnea
Epigastric dyscomfort

Diaphoresis
Pale cool skin Sinus tachycardia

Basilar rales
Hypotension

Grading of Angina Pectoris According to CCS Classification


Class I II

Description of Stage

Ordinary physical activity does not cause angina Slight limitation of ordinary activity.

Grading of Angina Pectoris According to CCS Classification


III IV

Marked limitations of ordinary physical activity.

Inability to carry on any physical activity without discomfort.

Anti-ischemic agents

Anticoagulants
Antiplatelets Coronary revascularization

Long term management

Medical treatment: Must be placed at bed rest w/

continous ECG monitoring for ST-segment deviation and cardiac rhythm.


Oxygen
Anti-ischemic treatment:
Nitrates: given sublingually

Anti coagulant:
Fondaparinux 2.5 SQ, Enoxaparin 1 mg/kg subcutaneously q12

Antiplatelets:
ASA, initial dose of 160-325 mg followed by 75-100mg

OD Clopidogrel, Loading dose of 300-600mg followed by 75mg daily.

Fundaparinux:

Catalyzes factor Xa inhibition by antithrombin and does not enhance the rate of thrombin inhibition.
Is cleared unchanged via kidneys , it is contraindicated in

patients w/ a creatinine clearance of < 30 ml/min.


ASA: antithrombotic effect by irreversely acetylating and

inhibiting paltelet cyclooxygenase (COX)1.


Clopidogrel: Antiplatelet
The drug irreversibly inhibits the P2Y subtype of ADP receptor,

which is important in aggregation of platelets and cross-linking by the protein fibrin. The blockade of this receptor inhibits platelet aggregation by blocking activation of the glycoprotein IIb/IIIa pathway.

Atorvastatin: inhibit HMG reductase. Lactulose: The metabolites of lactulose draw water into the

bowel, causing a cathartic effect through osmotic action.


Trimreazidine: an anti-ischemic metabolic agent, which

improves myocardial glucose utilization through inhibition of fatty acid metabolism, also known as fatty acid oxidation metabolism.
Furisemide: loop diuretic. By inhibiting the transporter, the

loop diuretics reduce the reabsorption of NaCl

Lanzoprazole: Proton pump inhibitor (PPI) which

prevents the stomach from producing gastric acid.


Dopamine: acting on the sympathetic nervous system,

producing effects such as increased heart rate and blood pressure.

Long term management:


Recommendation for lipid lowering therapy:
Statins are recommended for all NSTE-ACS patient,

irrespective of cholesterol levels, in the aim of achieving LDLc < 2.6 mmol/L.
Use of beta-blocker
BB are appropraite anti-ischemic therapy and may help

decrease triggers for MI.


Use of ACE-inhibitors
Recommended for plaque stabilization.

Long term management:


Recommendation for lipid lowering therapy:
Statins are recommended for all NSTE-ACS patient,

irrespective of cholesterol levels, in the aim of achieving LDLc < 2.6 mmol/L.
Use of beta-blocker
BB are appropraite anti-ischemic therapy and may help

decrease triggers for MI.


Use of ACE-inhibitors
Recommended for plaque stabilization.

Long term management:


Antiplatelet: therapy, recommended to be

combination of aspirin and clopidogrel for at 9-12 months.

Thank You