Established Myocardial Infarction

Malcolm Boersma

18/07/2013 48 y/o Indian Male came to casualty at 20:40 C/O sub-sternal chest pain, radiating to left arm, SOB and paresthesia since 13:00.

Details

~8 hours ago, chest pain, radiating to the left, paresthesia in the left arm and shortness of breath, diaphoresis. He was resting at home.

MVA 2012, injury to R arm

No other Hx Smokes +-20 cigarettes a day, diet, family Hx

History

Pt in pain, crouching over.

Patient was thin and warm to touch.

Bilateral wheezes.

No other significant findings

Physical exam & findings

ECG 18/07/13

Inferior anterolateral MI V4R showed involvement

ECG

Vital signsTime 20:45 21:00 21:20 21:35 01:00 07:00 08:50

RR 30 30 33 22 22 18 20

HR 105 93 96 94 104 88 70

P 105 93 96 94 104 88 70

BP 118/90 124/90 121/72 115/78 101/85 87/53 86/56

MAP 99 101 88 90 90 64 66

PULSE PRESS.

28 34 49 37 16 34 30

CAP <2 <2 <2 <2 <2 <2 <2

SKIN W W W W C C C

GCS 15 - - - - - -

PUPIL PEARRL - - - - - -

SP02 95 96 99 99 - - -

RBSL 7.4 - - - - 7.6 -

20:50-02, IV & 150 mg ASA

21:15- admitted into CCU, Bloods drawn & discussed with IALCH for angio

21:35- 300mg Clopidogrel

23:00- Tridil infusion was admin. to the patient.

06:00- prescribed medicine given

Management

Doctor’s prescription for patient management

- Aspirin, 150mg daily PO (COX 1 & 2 Inhibitor)

-Clopidogrel, 75mg daily PO (Anti-platelet- interferes with

function)

- Atorvastatin (Lipitor), 20mg daily PO (lowers LDL +

Triglycerides)

- Enalapril, 5mg daily PO (ACE-I)

-Enoxaparin 60mg dly s/c (LMW Heparin)

Medications

Analysis of findings

EF of 42% LVA Thrombus formation in apex of LV

Echocardiogram

Persistent ST elevation showsVentricular Aneurysm

Ribeiro, A. L. et al. (2012)

The infarcted muscle is replaced by a thin layer of collagenous scar tissue, that will gradually stretch as intraventricular pressure rises during systole.

ECG 25/07/13

Inferior anterolateral MI

Diagnosis

Follow up• Patient discharged 25/07/13• Scheduled for angio on 25/09/13

The biggest problem for this patient was the inability of him and the family members to recognise that he was having a heart attack. This is one of the biggest delays to treatment and causes of a high mortality rate. If the patient had recognised that he was having an AMI all the resources would have been available. The patient would have had a better outcome and a better quality of life.

conclusion

Physician, A.F. (2001) American Family Physician, 1 October, [Online], Available: http://www.aafp.org/afp/2001/1001/p1261.html [16 August 2013].

Early prevention of left ventricular dysfunction after myocardial infarction with angiotensin-converting-enzyme inhibition

The Lancet, Volume 337, Issue 8746, Pages 872-876N Sharpe, H Smith, J Murphy, S Greaves, H Hart, G Gamble

Ribeiro, A. L. et al. (2012) Diagnosis and management of Chagas disease and cardiomyopathy Nat. Rev. Cardiol. doi:10.1038/nrcardio.2012.109

References