CASE DISCUSSION ON ACUTE MYOCARDIAL INFARCTION

Bhavani Vegesena  

roll no:141


May 14, 2021

Case Discussion On Myocardial Infarction





I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

(Contains information collated from Dr.Manasa PG and from the patient)

Case:  A 60year old Male patient, resident of xxxxxxxx, came to the OPD with the  Chief complaint of chest pain since 3 days and giddiness and profuse sweating since morning.   

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic  3 days back and then he developed mild chest pain in the right side of the chest. The pain was insidious in onset and gradually progressive. The pain was of dragging type and was radiating to the back (retrosternal pain). 

There were no aggravating or relieving factors as such.

No H/O of fever, cold, cough, palpitations, SOB, pedal edema, facial puffiness, decrease urine output, nausea and vomiting .

Dizziness was not increasing or decreasing with change of position.

HISTORY OF PAST ILLNESS:

There were no similar complaints in the past.

The patient is a known case of hypertension and type 2 diabetes.

MEDICAL HISTORY:

The patient took the first dose of  COVISHEILD vaccine against COVID-19 5days back.

PERSONAL HISTORY:

APPETITE: normal
DIET: mixed
BOWEL AND BLADDER MOVEMENTS: normal
SLEEP: slightly disturbed for the past 3 days due to discomfort
ADDICTIONS: no addictions

FAMILY HISTORY:

No significant family history.

GENERAL EXAMINATION:

The patient was conscious, coherent and cooperative, sitting comfortably on the bed.

He is well oriented to time , place and person. 

He is thinly built and moderately nourished.

VITALS:

TEMPERATURE: afebrile

PULSE RATE: 48bpm

BLOOD PRESSURE: 110/80 mm hg

RESPIRATORY RATE: 14 cycles/min

SPO2: 96%

GRBS: 626mg/dl

On evaluation his GRBS was very high. He was immediately given 6U oh HAI iv and then his GRBS was checked which showed 506mg/dl so he was administered 16U of Actrapid. 

JVP: normal

No icterus, lymphadenopathy, edema.

SYSTEMIC EXAMINATION:

CVS:  SI, S2 heard. No murmurs 

RS: BAE + , NVBS

ABDOMEN: Soft and non tender

CNS: NAFD

INVESTIGATIONS:

COMPLETE URINE EXAMINATION:

BLOOD SUGAR- FASTING:


The patient was immediately treated for high blood sugar by giving 20U of actrapid.


LIVER FUNCTION TESTS:

INTERPRETATION: high total bilirubin, hypoalbuminemia.


RENAL FUNCTION TESTS:



 INTERPRETATION: increased urea, creatinine, uric acid and hyponatremia.


ELECTROCARDIOGRAM:

INTERPRETATION: elevations in lead 2 and lead 3 and AVF.


PROVISIONAL DIAGNOSIS: 

Information based on the above investigations is suggestive of inferior wall MI with uncontrolled  sugars with k/c/o DM since 8yrs.

TREATMENT:

On evaluation of the investigations, the patient was immediately administered with antiplatelets and anticoagulants STAT dose prophylactically and was advised for thrombolysis. The patients attenders wanted a cardiologist opinion ,so the patient has been referred to a higher center in view of PTCA.


DRUGS GIVEN:

TAB. ASPIRIN 325 mg PO/STAT

TAB ATORVAS 80mg PO/STAT

TAB CLOPIBB 300mg PO/STAT

INJ HAI 6U/IV STAT

VITAL MONITORING.

The patient was shifted to a higher center where he underwent angioplasty and a stent was placed. He was later discharged.

The patient is currently doing fine.


Clinical indications for PCI include the following:

  • Acute ST-elevation myocardial infarction (STEMI)
  • Non–ST-elevation acute coronary syndrome (NSTE-ACS)
  • Unstable angina.
  • Stable angina.
  • Anginal equivalent (eg, dyspnea, arrhythmia, or dizziness or syncope)
  • High risk stress test findings.

Example of intravascular ultrasonography (IVUS) image in percutaneous transluminal coronary angioplasty (PTCA).

Reference: https://emedicine.medscape.com/article/161446-overview


MYOCARDIAL INFARCTION:

Myocardial infarction (MI) (i.e., heart attack) is the irreversible death (necrosis) of heart muscle secondary to prolonged lack of oxygen supply (ischemia).



Reference: https://emedicine.medscape.com/article/155919-overview

ETIOLOGY:

Causes:

  • Atherosclerosis – Also known as coronary artery disease, this condition is the most common cause of heart attacks and occurs when the buildup of fat, cholesterol, and other substances forms plaque on the walls of the coronary arteries
  • Coronary artery spasm – A rare cause of blockage, spasms of the coronary arteries can cause them to become temporarily constricted. 
  • Coronary artery tear – Also known as a spontaneous coronary artery dissection, a tear in a coronary artery can prevent blood from reaching the heart and cause a heart attack.
Risk factors:
  • High cholesterol
  • Hypertension
  • Smoking
  • Illicit drug abuse
  • Obesity
  • Stress
  • Type 1 DM
  • Family history

SYMPTOMS:

Severe pressure, fullness, squeezing, pain, or discomfort in the center of the chest that lasts for more than a few minutes
Pain or discomfort that spreads to the shoulders, neck, arms, or jaw
Chest pain that gets worse
Chest pain that doesn't get better with rest or by taking nitroglycerin 

Chest pain that happens along with any of these symptoms:
  • Sweating, cool, clammy skin, or paleness
  • Shortness of breath
  • Nausea or vomiting
  • Dizziness or fainting
  • Unexplained weakness or fatigue
  • Rapid or irregular pulse
TREATMENT:
  1. Intravenous therapy, such as nitroglycerin and morphine
  2. Continuous monitoring of the heart and vital signs
  3. Oxygen therapy to improve oxygenation to the damaged heart muscle
  4. Pain medicine to decrease pain. This, in turn, decreases the workload of the heart. The oxygen demand of the heart decreases.
  5. Cardiac medicine such as beta-blockers to promote blood flow to the heart, improve the blood supply.
  6. Fibrinolytic therapy. This is the intravenous infusion of a medicine that dissolves the blood clot, restoring blood flow.
  7. Antithrombin or antiplatelet therapy with aspirin or clopidogrel. 
  8. Antihyperlipidemics. These medicines lower lipids (fats) in the blood, particularly low density lipid (LDL) cholesterol. 
Coronary angioplasty:

Angioplasty is a procedure to restore blood flow through the artery. It is also called percutaneous transluminal coronary angioplasty ( PTCA). 

Types:
  • Balloon angioplasty
  • Coronary stent
  • Atherectomy
  • Laser angioplasty

Coronary artery bypass:

Coronary bypass surgery redirects blood around a section of a blocked or partially blocked artery in your heart. The procedure involves taking a healthy blood vessel from your leg, arm or chest and connecting it below and above the blocked arteries in your heart. With a new pathway, blood flow to the heart muscle improves.
                  This procedure doesn't cure the condition but provides symptomatic relief and sometimes increases the heart function and reduce mortality.



RESEARCH PAPERS: 
Does primary stenting preserve cardiac function in myocardial infarction? A case–study. https://heart.bmj.com/content/84/5/515 int_source=trendmd&int_medium=cpc&int_campaign=usage-042019

Coronary stenting in patients undergoing PTCA during acute MI.         https://pubmed.ncbi.nlm.nih.gov/8651117/

Percutaneous transluminal coronary angioplasty with stents versus coronary artery bypass grafting for people with stable angina or acute coronary syndromes.https://pubmed.ncbi.nlm.nih.gov/15674954/



Note: The information above has been obtained from various sources that I have referenced and acknowledged with their online links and I have paraphrased them further. However the images I have borrowed may have copyright issues as they may not be certified through a creative commons license in which case I hope the original authors will get in touch with me and I shall remove them if they wish. 





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