Acs – inferior wall myocardial infarction. by abhimanyu

A very informative case on ACS for budding Clinical pharmacists, it covers Classification of ACS with types of MI's as well pharmaceutical care plan for the management of ACS

1. Case on ACS – Inferior wall Myocardial Infarction By: Abhimanyu Parashar 5 th Pharm.D 12/10/2012 1

2. ACS 12/10/2012 2

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4. Myocardial infarction Myocardial infarction  ( MI ) or  acute myocardial infarction  ( AMI ), commonly known as a  heart attack Typical symptoms of acute myocardial infarction: C hest pain (typically radiating to the left arm or left side of the neck)  shortness of breath N ausea V omiting P alpitations S weating A nxiety F atigue 12/10/2012 4

5. Classification There are two basic types of acute myocardial infarction based on pathology: 1. Transmural : Anterior Posterior Inferior lateral Septal 2. Subendocardial : Involving a small area in the subendocardial wall of the left ventricle, ventricular septum, or papillary muscles 12/10/2012 5

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7. A 2007 consensus document classifies myocardial infarction into five main types Type 1 – Spontaneous myocardial infarction Type 2 – Myocardial infarction secondary to ischemia Type 3 – Sudden unexpected cardiac death, including cardiac arrest Type 4 – Associated with   coronary angioplasty or stents Type 5 – Myocardial infarction associated with CABG 12/10/2012 7

8. Age : 63 years IP No. 1289064 Unit : Vikram Hospital (Dept. Cardiology) 12/10/2012 8

9. Reasons for admission C/O: Acute onset of Retro- sternal burning sensation Mild sweating Giddiness 12/10/2012 9

10. Patients History PMHx: K/C/O Type 2 DM with Hypertension since 5 years on Tab. Amace ( Amlodipine + Enalpril ) 1-0-0 Tab. Ecosprin (Aspirin 150 mg) 0-1-0 Tab. Dibizide M ( Glipizide + Metformin )1-0-0 Tab. Melmet 500 ( Metformin ) mg 0-0-1 SHx: Smoker since 1 year Alcoholic 12/10/2012 10

11. General examination BP : 120/80 mmHg Pulse : 80 BPM CVS: S1S2 + ECG: Inferior Wall MI Impression : ACS- IW.MI with T2DM and HTN ADV : 2-D ECHO, Troponin -I, CKMB, CPK, RBG, Hb , HCT, TC, S.Cr , Electrolytes, TSH. 12/10/2012 11

12. DAY 1 BP : 120/80 mmHg Pulse : 80 BPM CVS :S1S2 + 2D ECHO: IHD , Hypo-kinetic basal Inferio -Posterior wall Ejection fraction: 50 % Troponin I: + ve Impression: ACS At 9 PM : GC stable , No Angina/ Dyspnea Vitals : Normal ADV: CST CBG (BB): 177 mg/dl CBG (BL): 231 mg/dl CBG (BD): 102 mg/dl 12/10/2012 12

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14. Lab Reports Biochemistry CPK 170 (55-170 U/L) CKMB 6.25 (0-3.38 ng /ml) TROP-I 0.086 (0-0.035 ng /ml) Glucose (R) 245 mg/dl Urea 21 mg/dl S.Cr 0.80 mg/dl electrolytes Sodium 132 mg/dl Potassium 4.6 mg/dl TSH 3.49 (0.465-4.68 micro IU/ml) Hematology Hb . 15 HCT 41.9 % ( 42 to 52 %) MCV 87.7 fl ( 80 to 96 fl ) MCH 31.4 ( 27-33 pg /cell ) RBC 4.78 Lakhs Cell/ cumm PLT 2.36 Lakhs cell/ cumm WBC 12160 cell/ cumm Polymorphs 75.8 % L 18 M 55 E 05 B 01 12/10/2012 14

15. Treatment chart Drugs Dose R F Inj. Heparin 5000 U IV Q8H T. Aspirin 150 mg PO 0-1-0 T. Clopidogrel 75 mg PO 1-0-1 T. Trimetazidine MR 35 mg PO 1-0-1 T. Atorvastatin 40 mg PO 0-0-1 Syp . Cremalax (Na. Picosulfate ) PO 0-0-1 T. Pantoprazole 40 mg PO 1-0-0 T. Restyl ( Alprazolam ) 0.5 mg PO 0-0-1 T. Amace ( Amlodipine + enalpril ) 5 +5 mg PO 1-0-0 12/10/2012 15 Inj. Actrapid if sliding scale > 200 mg/dl T. Isosorbide Dinitrate 2.6 mg SL 1-1-0

16. DAY 2 BP : 130/80 mmHg Pulse: 88 BPM CVS: S1S2 + , SSM + RS: Clear ADV: CST, CAG counseling At 5 PM: GC fair , No Angina/ Dyspnea Troponin I: + ve ADV: CST and CAG after RFT RBG : 231 mg/dl CBG (BB): 172 mg/dl CBG (BL): 148 mg/dl CBG (BD): 245 mg/dl 12/10/2012 16

17. Thrombolysis in Myocardial Infarction 12/10/2012 17

18. Treatment chart DRUGS Dose R F Inj. Heparin 5000 U IV Q8H T. Aspirin 150 mg PO 0-1-0 T. Clopidogrel 75 mg PO 1-0-1 T. Trimetazidine MR 35 mg PO 1-0-1 T. Atorvastatin 40 mg PO 0-0-1 Syp . Cremalax PO 0-0-1 T. Pantoprazole 40 mg PO 1-0-0 T. Restyl (Na. Picosulfate ) 0.5 mg PO 0-0-1 T. Amace ( Amlodipine + enalpril ) 5+5 mg PO 1-0-0 T. Dibizide M ( Glipizide + Metformin ) 5+500 mg PO 1-0-0 T. Melmet ( Metformin ) 500 mg PO 0-1-1 T. Isosorbide Dinitrate 2.6 mg SL 1-1-0 Inj. Actrapid if sliding scale > 200 mg/dl 18

19. DAY 3 BP : 120/80mmHg Pulse : 72 BPM CVS : S1S2 + RS: NVBS + RBS: 172 mg/dl CBG (BB) : 180 mg/dl ADV: CAG and CST CAG report: Triple vessel disease PTCA + stent of OM + LCX Post CAG: TVD, No Angina/ Dyspnea Vitals: Normal ADV : CST , Counseling for PTCA + stent of OM and CLX 12/10/2012 19

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21. Coronary Angiography Reports 12/10/2012 21

22. Coronary Angiography Reports 12/10/2012 22

23. Treatment chart DRUGS Dose R F Inj. Heparin 5000 U IV Q8H T. Aspirin 150 mg PO 0-1-0 T. Clopidogrel 75 mg PO 1-0-1 T. Trimetazidine MR 35 mg PO 1-0-1 T. Atorvastatin 40 mg PO 0-0-1 Syp . Cremalax (Na. Picosulfate ) PO 0-0-1 T. Pantoprazole 40 mg PO 1-0-0 T. Restyl ( Alprazolam ) 0.5 mg PO 0-0-1 T. Amace ( Amlodipine + Enalpril ) 5=5 mg PO 1-0-0 T. Dibizide M ( Glipizide + Metformin ) 5+ 500 mg PO 1-0-0 T. Melmet ( Metformin ) 500 mg PO 0-1-1 T. Isosorbide Dinitrate 2.6 mg SL 1-1-0 Inj. Actrapid if sliding scale > 200 mg/dl 12/10/2012 23

24. DAY 4 BP : 120/80 mmHg Pulse : 80 BPM CVS : S1S2 + Post CAG – TVD NO Angina/ Dyspnea ADV: CST , Discharge 12/10/2012 24

25. Treatment chart DRUGS Dose R F Inj. Heparin 5000 U IV Q8H T. Aspirin 150 mg PO 0-1-0 T. Clopidogrel 75 mg PO 1-0-1 T. Trimetazidine MR 35 mg PO 1-0-1 T. Atorvastatin 40 mg PO 0-0-1 Syp . Cremalax (Na. Picosulfate ) PO 0-0-1 T. Pantoprazole 40 mg PO 1-0-0 T. Restyl ( Alprazolam ) 0.5 mg PO 0-0-1 T. Amace ( Amlodipine+Enalpril ) 5+5 mg PO 1-0-0 T. Dibizide M ( Glipizide + Metformin ) 5+ 500 mg PO 1-0-0 T. Melmet ( Metformin ) 500 mg PO 0-1-1 T. Isosorbide Dinitrate 2.6 mg SL 1-1-0 Inj. Actrapid if sliding scale > 200 mg/dl 25

26. DRUG DOSE R F 1 2 3 4 Inj. Heparin 5000 U IV Q8H + + + _ T. Aspirin 150 mg PO 0-1-0 + + + + T. Clopidogrel 75 mg PO 1-0-1 + + + + T. Trimetazidine MR 35 mg PO 1-0-1 + + + + T. Atorvastatin 40 mg PO 0-0-1 + + + + T. Cremalax (Na. Picosulfate ) PO 0-0-1 + + + + T. Pantoprazole 40 mg PO 1-0-0 + + + + T. Restyl ( Alprazolam ) 0.5 mg PO 0-0-1 + + + + T. Amace ( Amlodipine+Enalpril ) 5 + 5 mg PO 1-0-0 + + + + T. Dibizide M ( Glipizide + Metformin ) 5+ 500mg PO 1-0-0 _ + + + T. Melmet 500 mg PO 0-1-1 _ + + + 26 T. Isosorbide Dinitrate 2.6 mg SL 1-1-0 + + + + Inj. Actrapid if sliding scale > 200 mg/dl SC

27. Discharge Medication DRUG DOSE R F COST/TAB COST/DAY T. Aspirin 150 mg PO 0-1-0 0.80 Rs 0.80 Rs T. Clopidogrel 75 mg PO 1-0-1 6.2 Rs 12.40 Rs T. Trimetazidine MR 35 mg PO 1-0-1 7.5 Rs 15 Rs T. Atorvastatin 40 mg PO 0-0-1 20 Rs 20 Rs T. Amlopdipine+Enalpril 5+5 mg PO 1-0-0 4 Rs 8 Rs T. Glipiizide + Metformin 5+500 mg PO 1-0-0 0.75 Rs 0.75 Rs T. Metformin 500 mg PO 0-1-1 1.5 Rs 3 Rs T. Pantoprazole 40 mg PO 0-0-1 6 Rs 6 Rs T. Isosorbide Dinitrate 2.6 mg SL SOS __ 12/10/2012 27 Total : 66 Rs /Day

28. PHARMACEUTICAL CARE PLAN 12/10/2012 28

29. 12/10/2012 29 SUBJECTIVE EVIDENCE : Retro- sternal burning sensation Mild sweating Giddiness OBJECTIVE EVIDENCE: ECG : Inferior Wall MI 2D ECHO : IHD, Hypo-kinetic basal Inferio -Posterior wall Troponin I : + ve (0.086 ng /ml) CKMB : ( 6.25 ng /ml) CAG report : Triple vessel disease

30. Final Diagnosis ACS- Inferior wall MI with Triple Vessel Diseases with Hypertension and Type 2 Diabetes Mellitus 12/10/2012 30

31. Goals of Treatment Short term goals : Initial evaluation & stabilization Relief of ischemic chest discomfort Efficient risk stratification Focused cardiac care Early restoration of blood flow to the infarct-related artery to prevent infarct expansion. Increase myocardial oxygen delivery Prevention of death and other complications 12/10/2012 31

32. Long term goals : Prevent complications and recurrences. Reduce mortality and improve quality of life 12/10/2012 32

33. Treatment Options 12/10/2012 33 For Hypertension For IHD For T2DM ACE- inhibitors – Enalpril ARB’s – Telmisartan CCB’s- Dihydropyridine Amlodipine Diuretics – Furosemide Beta Blockers – Atenolol Metoprolol Anti-Platelet agents – Aspirin , clopidigrel Anti- anginal – Trimetazidine Nicorandil Ranolazine Anti- Hyperlipedimic agents – Atrovastatin Vasodilators- Nitrates Sulfonylureas – Glipizide Biguanides – Metformin Insulin

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35. 12/10/2012 35 Signs and symptoms were reduced by day 2 Lipid profile not done GOALS ACHIEVED Problems Identified

36. Monitoring Parameters 12/10/2012 36 Disease related : Blood Pressure ECG 2D-ECHO Blood Glucose levels Hb A1c Lipid Profile Drug related : Platelets count Blood pressure

37. Patient Counseling 12/10/2012 37

38. About Disease 12/10/2012 38

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40. About PTCA Advantages : It can be done under local anesthesia . The procedure is faster. Recovery period is shorter and less painful The procedure does not leave a noticeable scar It is a useful procedure for patients unwilling or unable to undergo surgery . A repeat procedure, if required, is easier to perform than a repeat bypass surgery. 12/10/2012 40

41. Disadvantages : Coronary angioplasty can be used only if one or two arteries are affected It cannot be used in arteries that cannot be reached by the catheter It may not be effective against very hard atherosclerotic plaques . Restenosis may occur, especially if a stent is not placed during the procedure 12/10/2012 41

42. About Medications Name and purpose Dose and frequency Medication adherence Possible adverse effects Missed dose 12/10/2012 42

43. About life style modification Monday, 10 December 2012 43 Healthy life style with daily exercise ( the ADA recommends 150 min/week (distributed over at least 3 days) of aerobic physical activity) Self-Monitoring of Blood Glucose Nutritional recommendations Driving: no driving for 1month. after Ml. Flying: most airlines will not carry passengers for 2wk. post Ml and then only if able to climb 1 flight of stairs without difficulty

44. Physical activity : advise gradual increase in activity 2wk. after Ml stroll in garden or street 4wk. after Ml walk @ ½ mile/d. 4 to 6wk. after Ml increase to 2 miles/d. by 6wk. From 6wk increase the speed of walking; aim 2 miles in <30min. Sexual activity : resume after 6wk Return to work : Sedentary workers 4-6wk. after uncomplicated Ml Light manual workers 6-8wk. after uncomplicated Ml Heavy manual workers 3months after uncomplicated Ml 12/10/2012 44

45. Monitoring health : continue regular reviews at least annually for lifelong. Check for symptoms and signs of cardiac dysfunction (breathlessness, palpitations, angina). Secondary prevention Smoking cessation Hypertension ,Check BP and refer physician if >140/90 Alcohol withdrawl . 12/10/2012 45

46. Monday, 10 December 2012 46 Fat 20–35% of total caloric intake Saturated fat < 7% of total calories <200 mg/day of dietary cholesterol Two or more servings of fish/week provide -3 polyunsaturated fatty acids Carbohydrate 45–65% of total caloric intake (low-carbohydrate diets are not recommended) Sucrose-containing foods may be consumed with adjustments in insulin dose Protein 10–35% of total caloric intake (high-protein diets are not recommended) Other components Fiber -containing foods may reduce postprandial glucose excursions Nonnutrient sweeteners

47. THANK U 12/10/2012 47