CASE PRESENTATION

 
 
 

PRESENTED BY
GUPTA PRAKASH
 TAB, a 44 years old male
married filipino, a roman
catholic currently residing at
General data
& san agustin victoria , tarlac
Chief complaint city, came in due to chest
pain.
  1 day PTA, Patient had drunk spree ( more
than usual in short span of time) ; 3 bottles
History of of redhorse and 1/3rd of fundador).
present
illness  Ten hours PTA(7am) patient had
sudden,heavy,non radiating, continuous
sternal chest pain.
 No other associated symptom and was
brought to ER.
 • No history of
hypertension, diabetes
mellitus , pulmonary
tuberculosis or any
respiratory diseases.
Past medical • No accidents/ falls ,
history previous surgery ,
hospitalizations, Blood
transfusions.
• Unrecalled vaccination
history.
 No hereditary diseases
Family history like hypertension,
diabetes mellitus etc.
 • The patient is a smoker
(5pack per year),
• Heavy alcohol
consumer(four times a
Personal and week).
social history • No known allergies to
food or medications.
• There is no recent
travel history.
 REVIEW OF SYSTEMS

 General- (-) weight loss , (+) fatigue , (-) body weakness

 Skin- , (-) jaundice,(-) rashes, (-) cyanosis, (-) pruritis, (-) pallor
 Head and neck- (-) head ache, (-) lymphadenopathy, (-) edema,
(-)redness.
 Eyes- (-)discharge, (-) lumps, (-) swelling
 Ears- (-)discharge , (-)bleeding, (-) swelling
 Nose- (-) nasal mucous discharge, (-)bleeding, (-) edema
 Throat- (-)enlarged tonsils (-) masses, (-)bleeding gums,(-)
 REVIEW OF SYSTEMS

 Respiratory: (-) orthopnea, (-) dyspnea

 Cardiovascular : , (-) cyanosis, (-)edema, (-)paroxysmal nocturnal
dyspnea(-)heart murmur.
 Gastrointestinal : (-) anorexia , (-)vomiting, (-)nausea, (-) hematochezia,
 Peripheral vascular: (-) swelling in the vein, (-)swelling in the calves,
leg or feet.
 Urinary: (-)hematuria
 Neurologic : (-) paralysis, (-) tremors (-)seizures.
 Endocrine: (-)thyroid trouble, (-)excessive sweating
 Hematologic- (-) easy bruising, pallor or bleeding
 VITAL SIGNS
BLOOD PRESSURE : 130/90mmhg
CARDIAC RATE : 135
RESP. RATE : 16
TEMPERATURE : 36.8 0C
EXAMINATION SPO2 : 88%
 PHYSICAL EXAMINATION

 General : conscious, coherent,

 Skin :brown , warm to touch.
HEENT: Pink palpebral conjunctiva, Anicteric sclera, no ptosis, no
nasal discharge.
Neck : no masses and no cervical lymphadenopathy.
Thorax and lungs: symmetrical chest expansion,
 Cardiovascular system: Adynamic precordium, Tachycardia and normal
rhythm, (-) murmur
Abdomen: Flat, soft non-tender with normoactive bowel sounds,(+)
Epigastric pain
 Extremities: no clubbing, no cyanosis, no edema noted
DIFFERENTIALS

PEPTIC ULCER DISEASE

MYOCARDICAL
INFARCTION
DIFFERENTIALS

Peptic ulcer disease

Rule in Rule out
1. Chest pain 1. Nausea and Vomiting
2. Epigastric 2. Hematemesis
3. History of Smoking and 3. Dyspepsia(indigestion)
Chronic Alcoholism. 4. No Hx of NSAIDS Use
5. No previous Hx of PUD
 DIFFERENTIALS
Myocardial Infarction
Rule in Rule out
1. Acute Chest pain (Sub Sternal)
2. Levine's Sign
-
3. Tachycardia
4. Fatigue
5. Heavy Alcohol Intake prior to Attack
Silent Features

 44 y/o Male
 Chest pain
 Tachycardia and Fatigue
 Positive Troponin I
 ST segment elevation on ECG
Working diagnosis

ST-Elevation Myocardial Infarction

ANTEROLATERAL wall and Alcohol
Intoxication
Cardiac Biomarker

 Troponin I positive
ECG
ECG interpretation

 Presence of ST segment Elevation:

 1. On leads V2;V3;V4 ( Anterior wall
involved)
 2. On leads V5; V6; lead I and aVL
( Lateral wall Involved)

 This Myocardial Infarction is described

as STEMI Anterolateral
ACUTE CORONARY
OBJECTIVES

DISCUSS:
 PATHOPHYSIOLOGY
 CLINICAL PRESENTATION
 DIAGNOSTIC EVALUATION
 RISK STRATIFICATION
 ACS

STEMI NSTE-
ACS
UNSTABLE
NSTEMI ANGINA
(Evidence of
myocyte
necrosis)
 ST-Segment Elevation
Myocardial Infarction (STEMI)

Cause
 • Thrombus fully occludes the coronary artery
Signs and Symptoms
 • Pain with or without radiation to arm, neck and back, or epigastric
region
 • Shortness of breath, diaphoresis, nausea, lightheadedness, tachycardia,
tachypnea, hypotension or hypertension, decreased arterial oxygen
saturation (SaO2), and rhythm abnormalities
 • Occurs at rest or with exertion; limits activity
 • Longer in duration and more severe than in unstable angina (irreversible
tissue damage [infarction] occurs if perfusion is not restored)
Diagnostic Findings
 • ST-segment elevation or new left bundle branch block on
electrocardiography
 • Cardiac biomarkers are elevated
 Non–ST-Segment Elevation
Myocardial Infarction (NSTEMI)

Cause
 Thrombus partially or intermittently occludes the coronary artery
Signs and Symptoms
 • Pain with or without radiation to arm, neck, back, or epigastric region
 • Shortness of breath, diaphoresis, nausea, lightheadedness, tachycardia, tachypnea,
hypotension or hypertension, decreased arterial oxygen saturation (SaO2) and rhythm
abnormalities
 • Occurs at rest or with exertion; limits activity
 • Longer in duration and more severe than in unstable angina
Diagnostic Findings
 • ST-segment depression or T-wave inversion on electrocardiography
 • Cardiac biomarkers are elevated
Unstable Angina

Cause
 • Thrombus partially or intermittently occludes the coronary artery

Signs and Symptoms

 Pain with or without radiation to arm, neck, back, or epigastric region
 Shortness of breath, diaphoresis, nausea, lightheadedness,
tachycardia, tachypnea, hypotension or hypertension, decreased
arterial oxygen saturation (SaO2) and rhythm abnormalities
 Occurs at rest or with exertion; limits activity

Diagnostic Findings
 • ST-segment depression or T-wave inversion on electrocardiography
 • Cardiac biomarkers not elevated
PATHOPHYSIOLOGY

 Imbalance between oxygen supply and oxygen

demand
 Coronary plaque disruption (most common)
 Coronary arterial vasodilation
 Gradual intraluminal narrowing
 Increased myocardial oxygen demand
PATHOPHYSIOLOGY

 10% have stenosis of the left main coronary

artery
 35% have three-vessel CAD
 20% have two-vessel disease
 20% have single-vessel disease
 15% have no apparent critical epicardial coronary
artery stenosis
CLINICAL PRESENTATION

 SEVERE CHEST DISCOMFORT and has at least ONE

OF THREE features:
 (1) occurrence at rest (or with minimal exertion),
lasting >10 minutes
 (2) of relatively recent onset (i.e., within the prior
2 weeks)
 (3) occurs with a crescendo pattern (i.e., distinctly
more severe, prolonged, or frequent than previous
episodes)
Chest Discomfort

 A.Intense substernal pressure sensation; often described as

“crushing” and “an elephant standing on my chest.”
 B. Radiation to neck, jaw, arms, or back, commonly to the
left side.
 C. Similar to angina pectoris in character and distribution but
much more severe and lasts longer. Unlike in angina, pain
typically does not respond to nitroglycerin.
 D. Some patients may have epigastric discomfort.
 2. Can be asymptomatic in up to one-third of patients;
painless infarcts or atypical presentations more likely in
postoperative patients, the elderly, diabetic patients, and
women.
CLINICAL PRESENTATION

CHEST DISCOMFORT:
 Anginal equivalents may occur (dyspnea,
epigastric discomfort, nausea, or weakness)
instead of chest pain; more frequent in women,
the elderly, and patients with diabetes mellitus
DIAGNOSTIC EVALUATION

3 MAJOR NON-INVASIVE TOOLS:

1. ECG
2. Cardiac biomarkers
3. Stress testing
ECG
CARDIAC BIOMARKERS

 Troponin I/T
 CK-MB: less specific

*differentiate patient with NSTEMI vs Unstable

angina
Stess Test
DIAGNOSTIC EVALUATION

GOALS:
1.Recognize or exclude myocardial infarction
(MI) using cardiac biomarkers
2. Detect rest ischemia (using serial or
continuous ECGs)
3. Detect significant coronary obstruction at
rest with Coronary Computed Tomographic
Angiography (CCTA) and myocardial ischemia
using stress testing
RISK STRATIFICATION

 Wide spectrum of early (30 days) risk of death

(ranging from 1 to 10%)
 Scoring systems: Thrombolysis In Myocardial
Infarction (TIMI) Trials
TIMI SCORE

 Prognostication scheme that categorizes a

patient’s risk death and ischemic events
 Provides a basis for therapeutic decision-making
Thank You