Acute Myocardial Infarction

AGUSTIN, ALLYANNA
CALMA, DAVID
CARCILLA, JANE
PAZ, TRINA
Patient Presentation
Chief Complaint
Im having pain in my chest, and I feel like Im full of gas.
HPI
Lorraine Hunt is a 66 y/o woman who is transported to the ED by
paramedics with severe crushing, substernal chest pain for the last 3
hours that is associated with mild SOB, diaphoresis, and radiation to the
neck and both arms. In the ED, her chest pain was unrelieved by 3 SL
NTG tablets.
PMH
HTN x 20 years
Type 2 DM
Hyperlipidemia
Hysterectomy 30 years ago, ovaries intact

Patient Presentation
FH
Father died of an MI at age 54; mother died of breast cancer at
age 80. She has one sister who is 61 y/o, alive and well, and one
brother who is 58 y/o with HTN.
SH
No tobacco x 15 years; no EtOH x 15 years
ROS
Positive for some baseline CP for some time
All
NKDA

Patient Presentation
Meds
Amlodipine 10 mg po Q AM
Glyburide 10 mg po Q AM, 5 mg po Q PM
EC ASA 325 mg po QD
Gemfibrozil 600 mg po BID
PE
GEN
A & O woman, still with chest pain
VS
BP 130/78, P 82, RR 18, T 37.1C; Ht 5 10, Wt 86 kg
HEENT
PERRLA, EOMI, fundi benign, TMs intact
Patient Presentation
Neck
No bruits, mid JVD; no thyromegaly
Lungs
Few dependent inspiratory crackles, bibasilar rales, no wheezes
CV
PMI displaces laterally, normal S
1
and S
2
, no S
3
or S
4
Abd
Soft, nontender, liver span ~10-12 cm, no bruits
MS/Ext
Normal ROM; muscle strength on right 5/5 UE/LE, on left 4/5 UE/LE
pulses 2+, no femoral bruits or peripheral edema
Patient Presentation
Neuro
CN II-XII intact; DTRs decreased on left; Babinski (-)

Labs







ECG
2-5 mm ST segment elevation in leads V2 to V6
Assessment
Acute anterior MI
Na 134 mEq/L
K 4.4 mEq/L
Cl 102 mEq/L
CO
2
23 mEq/L
BUN 15 mg/dL
SCr 1.0 mg/dL
Glu 266 mg/dL
Ca 9.8 mg/dL
Mg 2.0 mg/dL
PO
4
2.4 mgdL
Chol 214 mg/dL
Trig 175 mg/dL
LDL 144 mg/dL
HDL 35 mg/dL
CPK 68 U/L
CK-MB 1.1 IU/L
CK-MB% ND*
Troponin I 0.3 ng/mL
Hgb 14.0 g/dL
Hct 44%
WC 5.0 x 10
3
/mm
3
Plt 268 x 10
3
/mm
3

PT 12.5 sec
aPTT 32.4 sec
INR 1.0
HbA
1c
1 mo ago 9.3%
*ND, not determined.
Questions
Problem Identification
1. a. Which findings in this patients case history are consistent with acute myocardial infarction?

b. Which risk factors for the development of coronary artery disease are present in this patient?

Desired Outcome
2. What are the goals of pharmacotherapy in this patient?

Therapeutic Alternatives
3. a. What feasible pharmacotherapeutic alternatives are available to treat this patient?
b. What nonpharmacologic alternative therapies might be used in this patient?

Optimal Plan
4. Based on the history and presentation, what drug therapy is indicated in this patient?

Outcome Evaluation
5. How should the recommended therapy be monitored for efficacy and adverse effects?

Clinical Course

The patient received aspirin, reteplase, IV heparin, IV nitroglycerin, metroprolol,
and lisinopril. Approximately 1 hour after initiation of reteplase therapy, the
patients chest pain and the St segment elevation on the ECG had resolved. The
patient was stable until 2 days after administration when she began to experience
chest pain at rest. With the recurrent chest pain, she was taken to the cardiac
catheterization laboratory. The cath revealed the culprit lesion to be a severe
proximal stenosis in the left anterior descending coronary artery. PTCA of the vessel
was successfully performed followed by placement of a coronary artery stent.
After the stent was placed, the patient received an abciximab infusion. Ejection
fraction by echocardiogram 3 days postinfarct was 35%. The remainder of the
patients hospital stay was uncomplicated, and she was discharged 7 days post-
MI.
Clinical Course
Outcome Evaluation
6. a. What discharge medications would be most appropriate for this patient?
b. What patient counseling information should you provide to this patient?
Problem Identification
1. a. what findings in this patients case history are consistent with
acute myocardial infarction?
Chest pain, pain characterized as severe crushing substernal chest
pain, which radiates to the neck and both arms, shortness of
breath, diaphoresis

b. what risk factors for CAD are present in this patient?
The history of hypertension, diabetes, hyperlipidemia, and a family
history of death caused by myocardial infarction of her father.
These are all risk factors for coronary artery disease (CAD) and are
also present in the patient.

Desired Outcome
2. What are the goals of pharmacotherapy in this patient?
The immediate therapeutic goals in treating this patient are:
1. To stop the progression of myocardial necrosis that develops
2. Restore coronary blood flow
3. Promote vasodilation to increase oxygenation to the cardiac muscles
4. To administer fibrinolysis to lyse thrombus in the affected coronary
artery
5. To prevent stroke secondary to HTN
6. To provide pain relief
7. To prevent complications
8. To address Dyslipidemia
9. To Control blood sugar
10. To prevent death.
Therapeutic Alternatives
3. A. What are the feasible pharmacotherapeutic alternatives are available to protect this
patient?

a. Nitrates (Nitroglycerin 0.4mg SL q5 min for 3 doses p.r.n. for chest pains.or Isosorbide-5-
mononitrate 2.5mg daily.)
This should be administered to diminish or control chest pain or discomfort by promoting
vasodilation to increase coronary blood flow and to reduce myocardial oxygen demand, thus
stopping further tissue damage to the cardiac muscles.
b. Morphine
This is a good analgesic for pain control.
c.Beta blockers such as Metoprolol
These are used to reduce the risk of reinfarction and ventricular fibrillation.

Therapeutic Alternatives
3. A. What are the feasible pharmacotherapeutic alternatives are available to protect this patient?

d. Aspirin 80mg 4 tabs, STAT 75-162mg/day or clopidogrel 75mg/day if aspirin is contraindicated
Should be given to all patients who have acute myocardial infarction as it decreases platelets, thus reducing
thrombus formation, and overall, increases coronary blood flow. Though the patient has 325mg of aspirin as
her maintenance, in the case of an acute MI, this should still be given. However, this may be discontinued later
on, during transfer to the ward, or during discharge, at the discretion of the cardiologist.
e. Ace Inhibitors
Given to high risk patients like the elderly ,those with anterior infarction, a prior infarction or those with
depressed LV function.
It reduces ventricular remodeling after infarction with subsequent reduction of risk of developing congestive
heart failure.
f. ARBs
These are administered to patients who cannot take ace inhibitors. These are the patients who have either
clinical or radiological signs of heart failure.

Therapeutic Alternatives
3. A. What are the feasible pharmacotherapeutic alternatives are available to protect this patient?

g. Reperfusion therapy via fibrinolysis (thrombolysis) using fibrinolytic agents such as streptokinase
and tissue plasminogen activators
To enhance reperfusion while minimizing bleeding complications, accelerated dosage regimens of t-PA
are recommended. The recommended regimen is a 15-mg bolus followed by a 50-mg infusion over 30
minutes and then the remaining 35 mg over 60 minutes.
h. Metformin+Glyburide
An additional oral hypoglycemic agent such as metformin should be added to the patients list of
maintenance medications as she is not responding that well to glyburide alone. A regimen of
metformin+glyburide (500mg/2.5mg) given 2x a day is sufficient enough. However, a follow-up check-
up conducted 4 months later is highly recommended to see the patients response to the added
medication. Metformin has also been shown to reduce weight, which is beneficial to the patient since
her BMI is 27, which means that she is slightly overweight.
i. Atorvastatin/statins
Atorvastatin is highly effective as it increases serum HDL, lowers triglycerides, cholesterol, and LDL. This
has also been shown to be cardioprotective as studies have shown that it can reduce atherosclerotic
formation.

Therapeutic Alternatives
3. b. what are the feasible nonpharmacotherapeutic alternatives might be used to protect
this patient?
a. Direct percutaneous transluminal coronary angioplasty (DPTCA) is an attractive
alternative to thrombolytic therapy. It may be used in patients with acute myocardial
infarction who have contraindications or failure in responding to thrombolytic therapy.
b. Complete bed rest without bathroom privileges
They should be kept at bed rest for the first 12 hours. This to prevent the heart from exerting effort
due to activity and thus prevent increase in the size of infarct. However if there are no
complications in the next 24 hours patient may now sit on bed.
c. Weight management
d. Complete cessation of smoking.
e. Blood pressure control
BP less than 130/80 since patient is Diabetic.
f. Physical Exercise
30 minutes of moderate intensity aerobic exercise 3 to 4 days per week

Therapeutic Alternatives
3. b. what are the feasible nonpharmacotherapeutic alternatives might be used to protect
this patient?
g. Lipid Control
Triglycerides of less than 200 mg/dl; LDL less than 100 mg/dl; less than 7% of total calories as
saturated fats and less than 200 mg/day of total cholesterol.
h. Abstinence from alcoholic drinks
i. Weight Management
BMI 18.5-24.9 kg/m2
Waist circumference in women less than 35 inches.
j. Low salt, Low carbohydrate diet
k. Stool softeners such as dioctyl sodium sulfosuccinate, foods rich in bulk should be given to
prevent constipation.
L. Diabetes Management
HbA1c less than 7%

Optimal Plan

4. Write a complete pharmacotherapeutic plan for this patient
a. clopidogrel 75mg or aspirin 80mg may be administered daily.
For prevention of thromboembolic phenomena that can lead to stroke and reinfarction,
clopidogrel 75mg or aspirin 80mg may be administered daily. Aspirin is an irreversible
cyclooxygenase activity interfering with platelet activation. Clopidogrel is an oral agent that
blocks ADP receptor mediated platelet aggregation.
b. metoprolol
To control blood pressure, an ACE-inhibitor such as captopril 25mg twice a day, and the patients
amlodipine should be discontinued as the patient is showing signs of congestive heart failure.
Ideally, an ACE-inhibitor such as lisinopril and a beta blocker such as metoprolol should be given.
c. Metformin +Glyburide
To control the patients diabetes, metformin 500mg combined with glyburide 2.5mg may be given
two times a day in order to control the patients blood glucose levels since she is not adequately
responding to glyburide alone. This is evident by the high HbA1c levels of the patient, which is
9.3%. The normal value for this test should be around 4-6%.
Optimal Plan

4. Write a complete pharmacotherapeutic plan for this patient

d. Insulin
Insulin should be administered to the patient as well.
e. Atorvastatin
Atorvastatin may be administered to control the patients dyslipidemia as it acts as an HMG-COA
reductase inhibitor, exhibits pleotropic effects; plaque stabilization, anti-inflammatory effects.
Gemfibrozil should be discontinued as the combination of both medications may lead to a drastic
increase in the patients ALT/AST levels.
f. Isosorbide
Isosorbide dinitrate (5mg) may be administered as needed for chest pain as it promotes systemic
venodilation with reduction in left ventricular and diastolic volume and pressure, thereby reducing
myocardial wall tension and oxygen requirements.
Outcome Evaluation
5. How should the selected parameters be monitored for efficacy and adverse effects
a. Monitor of Blood Pressure
The patients blood pressure should be constantly monitored. Since the patient is taking an ACE-
inhibitor, the patient should be asked if she is disturbed with her coughing as this is one of the side
effects of this medication.
b. Monitoring of Blood Sugar
The patients blood sugar should be monitored as well. Tests such as an RBS, FBS, or preferably
HbA1c should be performed.
c. Monitor Lipid profile
The patients total cholesterol, HDL, LDL, and triglycerides should also be monitored.
d. Liver function tests
Such as ALT and AST should be performed regularly since Atorvastatin may increase the levels of
these enzymes.
e. Monitor CBC and platelet counts
Particularly her platelet concentration for she is taking Aspirin or Clopidogrel.

Outcome Evaluation

6. Discharge
Aspirin 80mg or Clopidogrel 75mg OD PO
Metoprolol 25mg BID
Metformin+ Glyburide (500mg/2.5mg) BID
Atorvastatin 80mg OD, PC, at night
Isosorbide dinitrate PRN
Patient counseling:
The patient must be encouraged to follow the lifestyle modifications advised by the physician.
These include weight management, physical exercise, low salt, fat, and carbohydrate diet,
and abstinence from smoking and drinking alcoholic beverages. The patient has to know the
possible adverse effect she may notice and report them immediately to her physician. The
patient must be encouraged to strictly comply to the regimen given to her and she must visit
her physician for follow-up check-ups and monitoring. Patient is advised to regularly monitor
blood sugar