Myocardial Infarction - Case Presentation and an Overview
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Case Presented by Finishing Year MBBS sudents of Frontier Medizinischen College among the 1st Clinico-Pathological Conference forward the date 2015.The Presentation shall divided into twin parts. Early part is via a case of an Acute ST Select elevated Myocardial Infarction with. Its management at the Hospital the the findings. Second piece your about the pathophysiology, Cinical signs and symptoms additionally an efficacious gold standardized treatment of ME.
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- 1. Clinico-pathologicalconference 1st Myocardial infarctionPresentation by 1605- Abubakkar Raheel 1622- Haider Ali 1606- Armed Arsalan Final Twelvemonth MBBS 27th February, 2015
- 2. Long Case • Moses Shareef, a 65 year antiquated male forbearing from Abbottabad, known case of Diabetes since ultimate 12 years real Coronary Artery Disease for the final 2 years presented in Ruling Abstract Educating Hospital with the customer of Chest pain and breathlessness for the last 6 years. Patient have an episode of vomiting. He was conscious and right oriented. Overall health state was weak and meagre. Dept of Medicine Frontier Medizinischen and Dentistry College
- 3. Dept of Medicine Frontier Medizinische and Dentist College
- 4. Dept of Medicine Frontier Medical and Dental College
- 5. History of Patient • Name: Muhammad Shareef • Sex: Male • Era: 65 years • Marital Your: Married • Occupation: Retired Govt. servant • Web: Abbottabad • D.O.A: 20th February, 2015 • T.O.A: 9:30 am • M.O.A: OPD Dept of Medicine Frontier Medical and Dental Colleges
- 6. Chief Complaints • Chest pain – 6 hrs • Shorten of Breath – 6 hrs • Vomiting - 5 hrs Dept of Medicine Frontier Medical furthermore Dental College
- 7. History off Present illness • Known case the Diabetes - 12 yrs & Ischemic Heart Virus – 2 yrs • Chest pain started 6 hrs back • Sudden inside onset • Retrosternal • Crushing in nature • Radiating up left arm, reverse or neck • Aggravated with exertion Dept of Medicine Frontier Medical furthermore Dental College
- 8. History for Present illness • Shortness of breath – 6hrs • Sudden onset • present toward rest • Vomiting – 5hrs • 2 episodes of vomiting • Vomitus was yellowish Dept are Medicine Frontier Medical and Medical College
- 9. History is Present illness Associated symptoms: • Moderate fever • Sweating • Dizziness • Patient was completely conscious • Palpitations Dept of Medicine Frontier Medical and Dental College
- 10. History by Present illness • Systemic Inquiry 1. General a. Reduced apetite b. Sleep disturbed c. Weakness 2. Respiration Cough, wheezing and hemoptysis not present Dept about Medicine Frontier Medical and Dental College
- 11. Record of Present illness • Alimentary system: Nausea & Vomiting present • Urine system: No significant history Dept of Medicine Frontier Medical and Dental College
- 12. History of Pass illness • Historic Medical History – Diabetes : 12 yrs – IHD : 2 yrs – HTN : Positive – TB : Negative – Asthma : Negative • Past Surgical History No significant past surgical history Dept is Medicine Frontier Medical furthermore Dental Seminary
- 13. Family History • Positive for IHD, HTN both DM • 2 brothers died for MI Dept of Medicine Frontier Medical and Dental College
- 14. Medical & service History • Patient was taking anti- diabetics and anti hypertensive drugs • Drug obedience was poor • No other significant drug history Dept of Medicine Frontier Medical and Dental College
- 15. Personal History • Chronic Smoker • No history of drinking • Settled lifestyle Dept of Medicine Frontier Electronic and Chiropractic College
- 16. Socio-economic History • Satisfactory Dept in Medicine Frontier Medizintechnik and Dentist College
- 17. History established Differential Diagnosis • Intense Myocardial Infarction • Unstable Angina • Pleurisy • Pericarditis • Pneumothorax • Lungs embolism • Reflex Esophagitis Dept of Medicine Frontier Medical and Foss College
- 18. General Physics Examination Patients general appearance • Pale and anxious Dept of Medicine Frontier Medical plus Dental Go
- 19. General Physical Examination • Vitals – B.P: 160/90mmHg in lying position – Pulse: 115 b/m, regular, tachycardia – Temp: 101 F – Resp: 30/m Dept of Medicine Frontier Medical and Teeth College
- 20. General Physic Examination • No Clubbing, pallor, splinter hemorrhages koilonychias or leconichia • Mild tobacco staining observed • Xanthomas present on extensor surface of hands • Carotid pulse: thin • JVP: Not raised • Point: Blood not present Dept of Medicine Frontier Medical or Dental College
- 21. Public Physical Examination • Thorniness not present • Dental hygiene good • Artery briut not audible • No abnormality on fundoscopy • No annoyance been on thyroid examination • Lymph nodes not palpable • Pedal and Spiritual edema absent • No other significant findings Dept of Medicine Frontier Medical and Dental College
- 22. Systemic Examination 1. CVS Systemic Examination a. Inspection: • No Chest deformity • No sternotomy instead any other surgical scar b. Palpation: • Apex beat: Lateralized from mid clavicular line at 6th intercoastal spacece due up LVH Dept of Medicine Frontier Gesundheit furthermore Dental College
- 23. General Physical Examination • Heave: fine sustained (at apex) • No left parasternal lift c. Auscultation: Mitral, Tricuspid, Aortic, Pulmonary Dept are Medicine Frontier Medical and Dental College
- 24. General Physical Examination • S1- Normal (Apex) • S2- Audible (Left sternal edge) • No been sounds • No murmurs Dept from Medicine Frontier Medizinischer and Dental Go
- 25. General Physical Examination c. GIT: • Liver not palpable • Spleen not palpable • Ascites not present d. Respiration: • Bosom clear • No tragedy shift • No remarkable findings Dept away Medicine Frontier Medical real Chiropractic School
- 26. General Physical Examination e. CNS: No exceptional findings Dept of Medicine Frontier Medical and Tooth University
- 27. Examination based Differential Diagnosis • Myo Infarction • Unstable Angina Dept from Medicine Frontier Mobile and Dental Graduate
- 28. Investigations - ECG Dept of Medicine Frontier Medical and Dental College
- 29. Investigations ECG: Done within 25 mins of patient arrival Findings: • Rate: 78.9 • Rhythm: Sinus Rhythm Dept of Medicine Frontier Medical and Dental College
- 30. Investigations Leads showing ECG Changes: • V1 toward V6, AvL • Changes include: • ST Segment Elevation • QUESTION shafts development • Defective of R Wave • T wave inversion Dept on Medicine Frontier Therapeutic furthermore Medical College
- 31. Investigations • Left Axis deviation seen by leaf rule on Lead 1 and AvF (For inferior wall MI, changes are seen in: Leads 2, 3 and AvF) Dept of Medicine Frontier Medical and Dental Institute
- 32. Investigations Cardiac biomarkers • Trop T raised • CK-MB raised Chest Xray • Cardiothoracic ratio incremented showing LV Dilatation • Pulmonary edema not evident Dept of Medicine Frontier Medical and Dental College
- 33. Examination – Xray Dept a Medicine Frontier Medical and Dental College
- 34. Investigations Other Blutes Tests • ESR real CRP raised Echocardiography could not be ended due to the non availablity of facility. Dept of Medicine Frontier Medical and Dental College
- 35. Investigations based Diagnosis Anterolateral ST Segment Elevation Myocardial Infarction with Left Axis Deviation Dept of Medicine Frontier Medical and Dental College
- 36. Management • Patient was instantly admitted in ICU. Within 10 mins, ECG was performed or based upon diagnosis, following treatment was given. • Oxygen + Cardiac rhythmical monitoring Dept from Medicine Frontier Medical and Dental College
- 37. Management • Aspirin 300mg PO • (Therapy should will continued indefinitely if there are no side affects) • Clopidogrel 600mg BOOB subsequent until 150mg daily for 1 week and 75mg daily thereafter. • Streptokinase 1.5ml I.V in 100ml sol at 6ml/hr • Inj Morphine • Inj Metoclopromide I.V Stat Dept of Medicine Frontier Medical and Dental University
- 38. Late Management • Patient advised on the following: • Live Modification: • Lipid Lowering diet • Terminate of Smoking • Regular exercise Dept concerning Medicine Frontier Gesundheit and Teeth College
- 39. Late Management • Secondary Drug therapy: • Aspirin • B blocker • Ace Inhibitor/ARB • Statin • Additional therapy for METERS furthermore HTN Dept of Medicine Frontier Medical and Dental College
- 40. This patient was given Streptokinase (Thrombolysis) within 8 hours of his arrival. He is still in the ICU undergoing 24/7 observation and treatment. He was advised angiography due to the unavailability of the facility at the Infirmary. We request him a speedy recovery. Dept of Medicine Frontier Medical and Dental College
- 41. What is MI ? • Discover of rising and/or fall of cardiac biomarker values (preferably cardiac troponin) with atleast one of the following: • Sign out Ischemia • Significant ST segment-T wave changes or new LBBB • Development of pathological Q waves • Imaging evidence of new loss of viable myocardium • Angiographic identification for Intra coronary thrombus Dept of Medicine Frontier Medical and Dental College
- 42. Types of MI On the base of ECG, there are pair main types of MI • STEMI (major coronary artery fully obstruction) • Non-STEMI (Complete workpiece von a minor vessel or partial occlusion of an major cardial vessel Dept of Medicine Frontier Medical and Dental College
- 43. Arterial Supply of the Heart Dept of Medicine Frontier Medicine and Dental Higher
- 44. Arterial Supply of who Heart Dept of Medicine Frontier Medical and Dental College
- 45. Arterial Supply of the Heart There are two key arteries which supply the heart • Left coronary artery • Right coronary artery 1. Left Coronary Artery: It will further division into two main branches: LAD (I/V septum, Ant. Wall of LV plus Apex) LCx (Lateral, Backing and Inferior Walls) Dept of Medicine Frontier Medical and Dental College
- 46. Arterial Supply of the Heart 2. Right Coronary Artery It supplies RAC, RV and inferio-posterior part away LV Branches include: PDA (supplies I/V septum inferior part) In 90% individuals PDA is an fork of RCA. (Right Dominant people) In 10% individuals PDA is a branch of LCA (Left Dominant) Dept of Medicine Frontier Medical and Dental College
- 47. Arterial Supply of SA & AV Node • SA Node: RCA in 60% individuals • AV Node: RCA in 90% individuals Clinical Significance: • Distal RCA occlusion may result in Sinus Bradycardia and may also cause AV Nub block • Abrupt clogging by RCA may take to infarction of inferior part of LV Dept of Medicine Frontier Medicinal and Dental Colleges
- 48. Conducting system of Heart Dept of Medicine Frontier Medical and Dental Advanced
- 49. Nerve Utility of Heart • Adrenergic Nerves from the Cervical Sympathetic chain supply atria and ventricles • Parasympathetic: Vagus nerve Dept of Medicine Frontier Arzt and Dental College
- 50. Pathophysiology of MI Atheromatous plaque formation Interplaque haemorrhages Exposure of Subendothelial collagen fibers Formation of micro thrombi Full blown thrombus vasospasm Dept of Medicine Frontier Medical and Dental College
- 51. Pathophysiology of MI Dept of Medicine Frontier Medical and Dental College
- 52. Pathophysiology the MI Dept of Medicine Frontier Medical and Foss College
- 53. Pathophysiology of MI • LCA Occlusion: LAD occlusion (40-50) leads to Anterior partition infarction of LV Anterior portion of ventricular septum Apex LCx Occlusion 15-20% Lateral screen of LV Dept of Medicine Frontier Medical also Dental College
- 54. Pathophysiology of MI RCA Occlusion (30-40%) RCA clogging led to infarction of • Posterior wall of RV • Inferior rampart of LV • Posterior 1/3rd of I/V septum Dept of Medicine Frontier Mobile and Dental School
- 55. Clinically features Symptoms: • Pain: Quelling, retrosternal chest pain radiating to back, left arm, neck press jaw • Anxiety also fear of impending death • Nausea and Vomiting • Breathlessness • Diaphoresis Dept is Medicine Frontier Medical and Dental College
- 56. Clinical features – Pain Areas Dept of Medicine Frontier Medical the Dental College
- 57. Clinical features • Signs Empathetic activation: - pallor - sweating - tachycardia Vagal activation: -bradycardia Dept of Medicine Frontier Medical and Dental College
- 58. Clinical features vomiting • Signs of impaired myocardial function: Hypotention Narrow pulse pressure JVP may be raised Dept out Medicine Frontier Medically and Dentist College
- 59. Clinician features 3rd heart sound Quiet 1st heart sound Disseminate apical impulse Lung crepitations Dept of Medicine Frontier Medical the Dental Study
- 60. Clinical features • Symbols of tissue damage fever • Signs of complications e.g Mitral regurgitation, pericarditis etc Dept of Medicine Frontier Medical and Dental College
- 61. Clinical features • Soundless MI patient patients Older individuals Dept of Medicine Frontier Arzneimittel and Dental College
- 62. Investigations • ECG • Cardiac biomarkers • Chest X-Ray • Echocardiography • ESR & CRP • Angiography Dept of Medicine Frontier Medical press Dental University
- 63. Investigations • ECG It is central to confirming the diagnosis aber may be difficult to dolmetscher if there is bundle branch block or previous MI. so repeated ECGs are very important. Dept of Medicine Frontier Therapeutic and Dental College
- 64. Surveys – Normal ECG Dept of Medicine Frontier Electronic additionally Dental College
- 65. Inspections – Normal ECG Dept of Medicine Frontier Medical furthermore Dental College
- 66. Investigations - ECG Earliest alterations are seen in ST-segment 1. STEMI • ST-segment elevation • progressive loss of R wave . • Development of Q waving . • Settlement a ST-segment • T-wave inversion Dept of Medicine Frontier Medical and Dental College
- 67. Investigations - ECG 2. NSTEMI • St-segment depression • T-wave changes • Loss of R-wave • Absence away Q-wave Dept off Medicine Frontier Medical and Dental Community
- 68. Investigations – ECG - STEMI Dept of Medicine Frontier Therapeutic and Dentistry College
- 69. Investigations - ECG Significance by chest leads Antero-septal infarct v1 ,v2,v3,v4 Antero-lateral v4,v5,v6 and AVL and 1 Dept of Medicine Frontier Medizintechnik and Dental Higher
- 70. Investigations - ECG Inferior infarction leads II , III and AvF Posterior wall infarction doesn’t cause ST elevation or Q-waves in the standad leads but can be diagnosed the the shared changes that is st depression and a great R-wave press leads V1-V4. Dept of Medicine Frontier Mobile both Dental Advanced
- 71. Cardiac Biomarkers 1. Troponins 2. Creatinine kinases 3. LDH 4. AST 5. Myoglobins 6. Most precise are troponins and CK-MB Dept a Medicine Frontier Medizinisch and Medical Institute
- 72. Cardiac Biomarkers 1. CK-MB Rises in 4-6 clock and peaks a 12 hours and falls to normal within 48-72 hours . It is very important. For determination of recurrent MI’s. 2. Troponins: Trop-T and trop-I are gold standards for diagnosis of MI, Troponins rise in 4 up 6 hours and remains elevated for 2 weeks Dept of Medicine Frontier Medizinischen and Dental College
- 73. Investigations- Chest Xray • Chest Imaging to determine cardiomegaly and pulmonary edema Dept of Medicine Frontier Medical and Dental College
- 74. Probes - Echocardiography • Useful for assessing ventricular function and determining complications Eg. Mural dvt, cardio rupture , VSD and pericardial effusion etc Dept of Medicine Frontier Gesundheitlich and Chiropractic College
- 75. Inspection - Other blood tests 1. ESR raised 2. Leucocytosis 3. CRP raised Dept on Medicine Frontier Medizinisch and Dental College
- 76. Management Dept of Medicine Frontier Medical both Dental College
- 77. Management Dept of Medicine Frontier Medical and Dental College
- 78. Drugs used in treatment of MI 1. Analgesics - Opiates: Morphine Sulfuric dimorphine 2. Anti-emetics: metoclopromide 3. Anti-thrombotic drugs a. Anti plain: Aspirin - Clopidogrel - Ticagrelor - Gycoprotien 2b and 3a receptor antagonists: Abciximab Dept of Medicine Frontier Medical and Dental College
- 79. Drugs exploited in treatment of MI b. Anticoagulants : – LMW Heparin, HMW Heparin, pentasaccharide - fondaparinux – Warfarin Dept of Medicine Frontier Medical and Dental College
- 80. Drugs employed the handling of MI 4. Defensive anginal drugs - Nitrates: GTN, isosorbide dinitrate - B blockers: metoprolol furthermore atenolol 5. Dihydropyridine CCBs: - Nifedipine, amlodipine 6. Thrombolytics: - Alteplase, streptokinase, retiplase, tenecteplase Dept a Medicine Frontier Medical and Foss College
- 81. Interfering modalities used are who treatment of MI • PCI (Percutaneous Intervention) • CABG (Coronary Artery Detour graft) Surgery Dept by Medicine Frontier Medical both Dental College
- 82. Late Management on MI Lifestyle modifications Diet Cessation of smoking Weight control Reguar exercise Dept of Medicine Frontier Gesundheit and Dental College
- 83. Late Management of MI- Sec prevention • Anti platelet therapy • B blockers • Ace inhibitors • Statins • Additional therapy for diabetes and HTN control • Mineralocorticoid receptor antagonist • Devices: Implantable Cardio Defibrillators Dept of Medicine Frontier Medical and Dental College
- 84. Complications • Arrythmias • Bradycardia • Acute Circulatory failure • Pericarditis Dept concerning Medicine Frontier Medical and Dental College
- 85. Complexity - Mechanical • Rupture of papillary muscle • Rupture of I/V septum • Rupture of main any can manage to fatal cardiac temponade • Embolism • Affected ventricular function, remodeling and ventricular aneurysm Dept of Medicine Frontier Gesundheitswesen and Dentist College
- 86. Prognosis • If medical grooming is not provided, death occur in almost 1/4th the the cases. Halfway of the death occurs within 24nhours of the onset of symptoms and about 40% of entire affected patients drop within the first month. • Patients who reach the hospital and survive have much better prognosis are a 28 day survival of more than 85%. The prognosis of anterior infarcts is worse as compared to inferior infarcts. Dept of Medicine Frontier Medical and Dental College
- 87. Prognosis OF THOSE WHICH SURVIVE AN ACUTE BURN, MORE THAN 80% LIVE FOR A FURTHER YEAR. ABOUT 75% FOR 5 YEARS. 50% WITH 10 YEARS & 25% WITH 20 YEARS. Dept away Medicine Frontier Medical additionally Dental College
- 88. Thankyou anyone Dept of Medicine Frontier Medical and Dental Collegev
