Myocardial Infarction - Case Presentation and an Overview

Case Presented by Final Year MBBS sudents of Frontier Medical College at the 1st Clinico-Pathological Conference for the year 2015.The Presentation is divided into two parts. First part is about a case of an Acute ST Segment elevated Myocardial Infarction with. Its management at the Hospital and the findings. Second part is about the pathophysiology, Cinical signs and symptoms and an effective gold standard treatment of MI.

1. Clinico -pathological conference 1st Myocardial infarction Presentation by 1605- Abubakkar Raheel 1622- Haider Ali 1606- Ahmed Arsalan 1611- Amaila Anam Final Year MBBS 27th February, 2015

2. Long Case Muhammad Shareef , a 65 year old male patient from Abbottabad , known case of Diabetes since last 12 years and Coronary Artery Disease for the last 2 years presented in King Abdullah Teaching Hospital with the complaints of Chest pain and breathlessness for the last 6 hours. Patient had an episode of vomiting. He was conscious and well oriented. Overall health state was weak and meagre . Dept of Medicine Frontier Medical and Dental College

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4. Dept of Medicine Frontier Medical and Dental College

5. History of Patient Name: Muhammad Shareef Sex: Male Age: 65 years Marital Status: Married Occupation: Retired Govt. servant Address: Abbottabad D.O.A: 20 th February, 2015 T.O.A: 9:30 am M.O.A: OPD Dept of Medicine Frontier Medical and Dental College

6. Chief Complaints Chest pain – 6 hrs Shortness of Breath – 6 hrs Vomiting - 5 hrs Dept of Medicine Frontier Medical and Dental College

7. History of Present illness Known case of Diabetes - 12 yrs & Ischemic Heart Disease – 2 yrs Chest pain started 6 hrs back Sudden in onset Retrosternal Crushing in nature Radiating to left arm, back and neck Aggravated on exertion Dept of Medicine Frontier Medical and Dental College

8. History of Present illness Shortness of breath – 6hrs Sudden onset present at rest Vomiting – 5hrs 2 episodes of vomiting Vomitus was yellowish Dept of Medicine Frontier Medical and Dental College

9. History of Present illness Associated symptoms: Moderate fever Sweating Dizziness Patient was completely conscious Palpitations Dept of Medicine Frontier Medical and Dental College

10. History of Present illness Systemic Inquiry 1. General a. Reduced apetite b. Sleep disturbed c. Weakness 2. Respiration Cough, wheezing and hemoptysis not present Dept of Medicine Frontier Medical and Dental College

11. History of Present illness Alimentary system: Nausea & Vomiting present Urinary system: No significant history Dept of Medicine Frontier Medical and Dental College

12. History of Past illness Past Medical History Diabetes : 12 yrs IHD : 2 yrs HTN : Positive TB : Negative Asthma : Negative Past Surgical History No significant past surgical history Dept of Medicine Frontier Medical and Dental College

13. Family History Positive for IHD, HTN and DM 2 brothers died of MI Dept of Medicine Frontier Medical and Dental College

14. Drug & treatment History Patient was taking anti diabetics and anti hypertensive drugs Drug compliance was poor No other significant drug history Dept of Medicine Frontier Medical and Dental College

15. Personal History Chronic Smoker No history of drinking Sedentary lifestyle Dept of Medicine Frontier Medical and Dental College

16. Socio-economic History Satisfactory Dept of Medicine Frontier Medical and Dental College

17. History based Differential Diagnosis Acute Myocardial Infarction Unstable Angina Pleurisy Pericarditis Pneumothorax Pulmonary embolism Reflex Esophagitis Dept of Medicine Frontier Medical and Dental College

18. General Physical Examination Patients general appearance Pale and anxious Dept of Medicine Frontier Medical and Dental College

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 Dental College

20. General Physical 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 Eyes: Anemia not present Dept of Medicine Frontier Medical and Dental College

21. General Physical Examination Jaundice not present Dental hygiene good Carotid briut not audible No abnormality on fundoscopy No abnormality seen on thyroid examination Lymph nodes not palpable Pedal and Sacral edema absent No other significant findings Dept of Medicine Frontier Medical and Dental College

22. Systemic Examination CVS Systemic Examination Inspection: No Chest deformity No sternotomy or any other surgical scar b. Palpation: Apex beat: Lateralized from mid clavicular line at 6 th intercoastal spacece due to LVH Dept of Medicine Frontier Medical and Dental College

23. General Physical Examination Heave: well sustained (at apex) No left parasternal lift Auscultation: Mitral, Tricuspid, Aortic, Pulmonary Dept of Medicine Frontier Medical and Dental College

24. General Physical Examination S1- Normal (Apex) S2- Audible (Left sternal edge) No added sounds No murmurs Dept of Medicine Frontier Medical and Dental College

25. General Physical Examination c. GIT: Liver not palpable Spleen not palpable Ascites not present Respiration: Chest clear No tracheal shift No remarkable findings Dept of Medicine Frontier Medical and Dental College

26. General Physical Examination e. CNS: No remarkable findings Dept of Medicine Frontier Medical and Dental College

27. Examination based Differential Diagnosis Myocardial Infarction Unstable Angina Dept of Medicine Frontier Medical and Dental College

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 to V6, AvL Changes include: ST Segment Elevation Q wave development Loss of R Wave T wave inversion Dept of Medicine Frontier Medical and Dental College

31. Investigations Left Axis deviation seen by thumb 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 College

32. Investigations Cardiac biomarkers Trop T raised CK-MB raised Chest Xray Cardiothoracic ratio increased showing LV Dilatation Pulmonary edema not evident Dept of Medicine Frontier Medical and Dental College

33. Investigations – Xray Dept of Medicine Frontier Medical and Dental College

34. Investigations Other Blood Tests ESR and CRP raised Echocardiography could not be done 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 immediately admitted in ICU. Within 10 mins , ECG was performed and based upon diagnosis, following treatment was given. Oxygen + Cardiac rhythm monitoring Dept of Medicine Frontier Medical and Dental College

37. Management Aspirin 300mg PO (Therapy should be continued indefinitely if there are no side affects) Clopidogrel 600mg PO followed by 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 College

38. Late Management Patient advised on the following: Lifestyle Modification: Lipid Lowering diet Cessation of Smoking Regular exercise Dept of Medicine Frontier Medical and Dental College

39. Late Management Secondary Drug therapy: Aspirin B blocker Ace Inhibitor/ARB Statin Additional therapy for DM and HTN Dept of Medicine Frontier Medical and Dental College

40. The 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 Hospital. We wish him a speedy recovery.  Dept of Medicine Frontier Medical and Dental College

41. What is MI ? Detection of rise and/or fall of cardiac biomarker values (preferably cardiac troponin ) with atleast one of the following: Symptoms of 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 of Intra coronary thrombus Dept of Medicine Frontier Medical and Dental College

42. Types of MI On the basis of ECG, there are two main types of MI STEMI (major coronary artery complete obstruction) Non-STEMI (Complete occlusion of a minor vessel or partial occlusion of a major coronary vessel Dept of Medicine Frontier Medical and Dental College

43. Arterial Supply of the Heart Dept of Medicine Frontier Medical and Dental College

44. Arterial Supply of the Heart Dept of Medicine Frontier Medical and Dental College

45. Arterial Supply of the Heart There are two major arteries which supply the heart Left coronary artery Right coronary artery Left Coronary Artery: It is further divided into two main branches: LAD (I/V septum, Ant. Wall of LV and Apex) LCx (Lateral, Posterior and Inferior Walls) Dept of Medicine Frontier Medical and Dental College

46. Arterial Supply of the Heart 2. Right Coronary Artery It supplies RA, RV and inferio -posterior part of LV Branches include: PDA (supplies I/V septum inferior part) In 90% individuals PDA is a branch 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: Proximal RCA occlusion may result in Sinus Bradycardia and may also cause AV Nodal block Abrupt occlusion of RCA may lead to infarction of inferior part of LV Dept of Medicine Frontier Medical and Dental College

48. Conducting system of Heart Dept of Medicine Frontier Medical and Dental College

49. Nerve Supply of Heart Adrenergic Nerves from the Cervical Sympathetic chain supply atria and ventricles Parasympathetic: Vagus nerve Dept of Medicine Frontier Medical and Dental College

50. Pathophysiology of MI Dept of Medicine Frontier Medical and Dental College

51. Pathophysiology of MI Dept of Medicine Frontier Medical and Dental College

52. Pathophysiology of MI Dept of Medicine Frontier Medical and Dental College

53. Pathophysiology of MI LCA Occlusion: LAD occlusion (40-50) leads to Anterior wall infarction of LV Anterior portion of ventricular septum Apex LCx Occlusion 15-20% Lateral wall of LV Dept of Medicine Frontier Medical and Dental College

54. Pathophysiology of MI RCA Occlusion (30-40%) RCA occlusion leads to infarction of Posterior wall of RV Inferior wall of LV Posterior 1/3 rd of I/V septum Dept of Medicine Frontier Medical and Dental College

55. Clinical features Symptoms: Pain: Crushing, retrosternal chest pain radiating to back, left arm, neck or jaw Anxiety and fear of impending death Nausea and Vomiting Breathlessness Diaphoresis Dept of Medicine Frontier Medical and Dental College

56. Clinical features – Pain Areas Dept of Medicine Frontier Medical and Dental College

57. Clinical features Signs Sympathetic 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 of Medicine Frontier Medical and Dental College

59. Clinical features 3 rd heart sound Quiet 1 st heart sound Diffuse apical impulse Lung crepitations Dept of Medicine Frontier Medical and Dental College

60. Clinical features Signs of tissue damage fever Signs of complications e.g Mitral regurgitation, pericarditis etc Dept of Medicine Frontier Medical and Dental College

61. Clinical features Silent MI diabetic patients Older individuals Dept of Medicine Frontier Medical and Dental College

62. Investigations ECG Cardiac biomarkers Chest X-Ray Echocardiography ESR & CRP Angiography Dept of Medicine Frontier Medical and Dental College

63. Investigations ECG It is central to confirming the diagnosis but may be difficult to interpret if there is bundle branch block or previous MI. so repeated ECGs are very important. Dept of Medicine Frontier Medical and Dental College

64. Investigations – Normal ECG Dept of Medicine Frontier Medical and Dental College

65. Investigations – Normal ECG Dept of Medicine Frontier Medical and Dental College

66. Investigations - ECG Earliest changes are seen in ST-segment STEMI ST-segment elevation progressive loss of R wave . Development of Q wave . Resolution of 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 of Q-wave Dept of Medicine Frontier Medical and Dental College

68. Investigations – ECG - STEMI Dept of Medicine Frontier Medical and Dental College

69. Investigations - ECG Significance of chest leads Antero- septal infarct v1 ,v2,v3,v4 Antero-lateral v4,v5,v6 and AVL and 1 Dept of Medicine Frontier Medical and Dental College

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 by the reciprocal changes that is st depression and a tall R-wave and leads V1-V4. Dept of Medicine Frontier Medical and Dental College

71. Cardiac Biomarkers Troponins Creatinine kinases LDH AST Myoglobins Most specific are troponins and CK-MB Dept of Medicine Frontier Medical and Dental College

72. Cardiac Biomarkers CK-MB Rises in 4-6 hours and peaks a 12 hours and falls to normal within 48-72 hours . It is very important. For diagnosis of recurrent MI’s. Troponins : Trop -T and trop -I are gold standards for diagnosis of MI, Troponins rise in 4 to 6 hours and remains elevated for 2 weeks Dept of Medicine Frontier Medical and Dental College

73. Investigations- Chest Xray Chest Xray to determine cardiomegaly and pulmonary edema Dept of Medicine Frontier Medical and Dental College

74. Investigations - Echocardiography Useful for assessing ventricular function and determining complications Eg . Mural thrombus, cardiac rupture , VSD and pericardial effusion etc Dept of Medicine Frontier Medical and Dental College

75. Investigations - Other blood tests ESR raised Leucocytosis CRP raised Dept of Medicine Frontier Medical and Dental College

76. Management Dept of Medicine Frontier Medical and Dental College

77. Management Dept of Medicine Frontier Medical and Dental College

78. Drugs used in treatment of MI Analgesics - Opiates: Morphine Sulphate dimorphine Anti-emetics: metoclopromide Anti-thrombotic drugs a. Anti platelets: Aspirin - Clopidogrel - Ticagrelor - Gycoprotien 2b and 3a receptor antagonists: Abciximab Dept of Medicine Frontier Medical and Dental College

79. Drugs used in treatment of MI b. Anticoagulants : LMW Heparin, HMW Heparin, pentasaccharide - fondaparinux Warfarin Dept of Medicine Frontier Medical and Dental College

80. Drugs used in treatment of MI 4. Anti anginal drugs - Nitrates: GTN, isosorbide dinitrate - B blockers: metoprolol and atenolol 5. Dihydropyridine CCBs: - Nifedipine , amlodipine 6. Thrombolytics : - Alteplase , streptokinase, retiplase , tenecteplase Dept of Medicine Frontier Medical and Dental College

81. Invasive modalities used in the treatment of MI PCI ( Percutaneous Intervention) CABG (Coronary Artery Bypass graft) Surgery Dept of Medicine Frontier Medical and Dental College

82. Late Management of MI Lifestyle modifications Diet Cessation of smoking Weight control Reguar exercise Dept of Medicine Frontier Medical 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 Cardiac Defibrillators Dept of Medicine Frontier Medical and Dental College

84. Complications Arrythmias Bradycardia Acute Circulatory failure Pericarditis Dept of Medicine Frontier Medical and Dental College

85. Complications - Mechanical Rupture of papillary muscle Rupture of I/V septum Rupture of ventricle which can lead to fatal cardiac temponade Embolism Impaired ventricular function , remodeling and ventricular aneurysm Dept of Medicine Frontier Medical and Dental College

86. Prognosis If medical care is not provided, death occurs in almost 1/4 th of the cases. Half of the death occurs within 24nhours of the onset of symptoms and about 40% of all affected patients die within the first month. Patients who reach the hospital and survive have much better prognosis with 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 WHO SURVIVE AN ACUTE ATTACK, MORE THAN 80% LIVE FOR A FURTHER YEAR. ABOUT 75% FOR 5 YEARS. 50% FOR 10 YEARS & 25 % FOR 20 YEARS. Dept of Medicine Frontier Medical and Dental College

88. Thankyou everyone  Dept of Medicine Frontier Medical and Dental Collegev