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ACUTE CORONARY SYNDROME

Case Presentation:

 The Patient is a 28 year old Male with chief complaint of Chest Pain which started at 9:00am that day. The
Patient refers that he had a sudden onset of Central Chest Pain (6/10) along with 2 episodes of Vomiting.
 He went to a private Institution where a troponin assay was done (11:00 am) which came back negative. Patient
was referred to GMPH and at the time of presentation to A/E had no complaints
 He has no previous medical or surgical history. He refers his
 mother died of a Myocardial Infraction some years ago.
 Physical Examination was unremarkable.

Pertinent Data:

 28 y.o. Male  Vomiting  R: 27 cpm


 Chest pain  T: 98.2 F  BP: 158/62 mmHg
 Family history of MI  P: 82 bpm  O2 sat: 95%
Differential Diagnosis for Severe Chest Pain

 Critical  Emergent  Non-emergent


o Acute Coronary o Pericarditis o Stable angina
Syndromes o Myocarditis o Asthma exacerbation
o STEMI o Pneumothorax o Valvular Heart Disease
o Non-STEMI o Mediastinitis o Pneumonia
o Unstable angina o Cholecystitis o Pleuritis
o Aortic Dissection o Pancreatitis o Tumor
o Cardiac o Cocaine chest pain o Esophageal Spasm
o Tamponade o Gastroesophageal Reflux
o Pulmonary Embolism Disease (GERD)
o Tension o Peptic Ulcer Disease
o Pneumothorax o Biliary Colic
o Rib Fracture
o Chostochondirits
o Panic attack

INVESTIGATION
ECG Echo
• ST segment elevation in leads V2, V3, AVF • No Structural Abnormalities
• Sinus Tachycardia
Blood Test
Cardiac Markers • Leukocytosis
• Troponin = 65 ng/dL ( 20:35hrs) • Elevated ESR/CRP
DIAGNOSIS

ACUTE CORONARY SYNDROME

• Acute coronary syndrome is a term


used to describe a range of
conditions associated with sudden,
reduced blood flow to the heart.
• It is almost always associated with
rupture of an atherosclerotic plaque
and partial or complete thrombosis
of the infarct-related artery.
• ACS leads to myocardial ischemia
and eventually necrosis which
results in compromised cardiac
functioning
Clinical Manifestations
• Chest Pain, Pressure or Heaviness • Syncope
• Palpitations • Shortness of Breath
• Pain Radiating to Neck, Jaw, Left Arm, Back • Nausea and Vomiting
and Epigastric Region • Diaphoresis and Decreased Exercise Tolerance

Management

Immediate Therapy: In Hospital within 12 hours

Management Percutaneous Coronary Intervention

• Immediate emergency reperfusion therapy has no demonstrable benefit in patients with non-ST segment
elevation MI and thrombolytic therapy may be harmful.
• In ST segment elevation acute coronary syndrome; Immediate reperfusion therapy restores coronary artery
patency, preserves left ventricular function and improves survival.
Management (Long Term Therapy)

Lifestyle modification Secondary prevention: Drug Others


• Diet (weight control, lipid- Therapy • Rehabilitation
lowering Mediterranean • Antiplatelet therapy • Implantable cardiac
diet) (aspirin and/or defibrillator
• Cessation of smoking clopidogrel)
• Regular exercise • β-blocker
• ACE inhibitor/ARB
• Statin
• Additional therapy for
control of diabetes and
hypertension
• Mineralocorticoid
receptor antagonist

Back to Our Patient

This Patient suffered an Inferior STEMI and was effectively managed in ICU with the following medication:
• Atorvostatin 80mg PO Nocte
• Aspirin 81mg PO OD
• Clopidigrel 75mg PO OD
• Inj Heperin 17000 U Sc BD
• O2 via F/M PRN
• GTN Po SL PRN
• Inj Morphine 5mg IV PRN