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Myocardial infarction

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Malcolm Boersma

A 48-year-old Indian male presented to the emergency department complaining of chest pain radiating to his left arm, shortness of breath, and numbness for the past 8 hours. His medical history included a motor vehicle accident in 2012 that injured his right arm. On examination, he appeared to be in pain and was warm to the touch with bilateral wheezes. He was diagnosed with an inferior anterolateral myocardial infarction and admitted to the cardiac care unit. His treatment included aspirin, clopidogrel, statins, and anticoagulants. He was discharged after one week with medications and a follow up appointment scheduled for cardiac catheterization.

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Malcolm Boersma
? 18/07/2013 48 y/o Indian Male came to casualty at 20:40 C/O sub-sternal chest pain, radiating to left arm, SOB and paresthesia since 13:00.
? ~8 hours ago, chest pain, radiating to the left, paresthesia in the left arm and shortness of breath, diaphoresis. He was resting at home. ? MVA 2012, injury to R arm ? No other Hx ? Smokes +-20 cigarettes a day, diet, family Hx
? Pt in pain, crouching over. ? Patient was thin and warm to touch. ? Bilateral wheezes. ? No other significant findings
Myocardial infarction
? Inferior anterolateral MI ? V4R showed involvement
Time 20:45 21:00 21:20 21:35 01:00 07:00 08:50 RR 30 30 33 22 22 18 20 HR 105 93 96 94 104 88 70 P 105 93 96 94 104 88 70 BP 118/90 124/90 121/72 115/78 101/85 87/53 86/56 MAP 99 101 88 90 90 64 66 PULSE PRESS. 28 34 49 37 16 34 30 CAP <2 <2 <2 <2 <2 <2 <2 SKIN W W W W C C C GCS 15 - - - - - - PUPIL PEARRL - - - - - - SP02 95 96 99 99 - - - RBSL 7.4 - - - - 7.6 -
20:50-02, IV & 150 mg ASA 21:15- admitted into CCU, Bloods drawn & discussed with IALCH for angio 21:35- 300mg Clopidogrel 23:00- Tridil infusion was admin. to the patient. 06:00- prescribed medicine given
? Doctor¡¯s prescription for patient management ? - Aspirin, 150mg daily PO (COX 1 & 2 Inhibitor) ? -Clopidogrel, 75mg daily PO (Anti-platelet- interferes with function) ? - Atorvastatin (Lipitor), 20mg daily PO (lowers LDL + Triglycerides) ? - Enalapril, 5mg daily PO (ACE-I) ? -Enoxaparin 60mg dly s/c (LMW Heparin)
Myocardial infarction
? EF of 42% ? LVA ? Thrombus formation in apex of LV
Persistent ST elevation shows Ventricular Aneurysm Ribeiro, A. L. et al. (2012) The infarcted muscle is replaced by a thin layer of collagenous scar tissue, that will gradually stretch as intraventricular pressure rises during systole.
Myocardial infarction
? Inferior anterolateral MI Follow up ? Patient discharged 25/07/13 ? Scheduled for angio on 25/09/13
The biggest problem for this patient was the inability of him and the family members to recognise that he was having a heart attack. This is one of the biggest delays to treatment and causes of a high mortality rate. If the patient had recognised that he was having an AMI all the resources would have been available. The patient would have had a better outcome and a better quality of life.
? Physician, A.F. (2001) American Family Physician, 1 October, [Online], Available: http://www.aafp.org/afp/2001/1001/p1261.html [16 August 2013]. ? Early prevention of left ventricular dysfunction after myocardial infarction with angiotensin-converting- enzyme inhibition ? The Lancet, Volume 337, Issue 8746, Pages 872-876 N Sharpe, H Smith, J Murphy, S Greaves, H Hart, G Gamble ? Ribeiro, A. L. et al. (2012) Diagnosis and management of Chagas disease and cardiomyopathy Nat. Rev. Cardiol. doi:10.1038/nrcardio.2012.109

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Myocardial infarction

  • 2. ? 18/07/2013 48 y/o Indian Male came to casualty at 20:40 C/O sub-sternal chest pain, radiating to left arm, SOB and paresthesia since 13:00.
  • 3. ? ~8 hours ago, chest pain, radiating to the left, paresthesia in the left arm and shortness of breath, diaphoresis. He was resting at home. ? MVA 2012, injury to R arm ? No other Hx ? Smokes +-20 cigarettes a day, diet, family Hx
  • 4. ? Pt in pain, crouching over. ? Patient was thin and warm to touch. ? Bilateral wheezes. ? No other significant findings
  • 6. ? Inferior anterolateral MI ? V4R showed involvement
  • 7. Time 20:45 21:00 21:20 21:35 01:00 07:00 08:50 RR 30 30 33 22 22 18 20 HR 105 93 96 94 104 88 70 P 105 93 96 94 104 88 70 BP 118/90 124/90 121/72 115/78 101/85 87/53 86/56 MAP 99 101 88 90 90 64 66 PULSE PRESS. 28 34 49 37 16 34 30 CAP <2 <2 <2 <2 <2 <2 <2 SKIN W W W W C C C GCS 15 - - - - - - PUPIL PEARRL - - - - - - SP02 95 96 99 99 - - - RBSL 7.4 - - - - 7.6 -
  • 8. 20:50-02, IV & 150 mg ASA 21:15- admitted into CCU, Bloods drawn & discussed with IALCH for angio 21:35- 300mg Clopidogrel 23:00- Tridil infusion was admin. to the patient. 06:00- prescribed medicine given
  • 9. ? Doctor¡¯s prescription for patient management ? - Aspirin, 150mg daily PO (COX 1 & 2 Inhibitor) ? -Clopidogrel, 75mg daily PO (Anti-platelet- interferes with function) ? - Atorvastatin (Lipitor), 20mg daily PO (lowers LDL + Triglycerides) ? - Enalapril, 5mg daily PO (ACE-I) ? -Enoxaparin 60mg dly s/c (LMW Heparin)
  • 11. ? EF of 42% ? LVA ? Thrombus formation in apex of LV
  • 12. Persistent ST elevation shows Ventricular Aneurysm Ribeiro, A. L. et al. (2012) The infarcted muscle is replaced by a thin layer of collagenous scar tissue, that will gradually stretch as intraventricular pressure rises during systole.
  • 14. ? Inferior anterolateral MI Follow up ? Patient discharged 25/07/13 ? Scheduled for angio on 25/09/13
  • 15. The biggest problem for this patient was the inability of him and the family members to recognise that he was having a heart attack. This is one of the biggest delays to treatment and causes of a high mortality rate. If the patient had recognised that he was having an AMI all the resources would have been available. The patient would have had a better outcome and a better quality of life.
  • 16. ? Physician, A.F. (2001) American Family Physician, 1 October, [Online], Available: http://www.aafp.org/afp/2001/1001/p1261.html [16 August 2013]. ? Early prevention of left ventricular dysfunction after myocardial infarction with angiotensin-converting- enzyme inhibition ? The Lancet, Volume 337, Issue 8746, Pages 872-876 N Sharpe, H Smith, J Murphy, S Greaves, H Hart, G Gamble ? Ribeiro, A. L. et al. (2012) Diagnosis and management of Chagas disease and cardiomyopathy Nat. Rev. Cardiol. doi:10.1038/nrcardio.2012.109