Grand Rounds 2

8/3/2019 Grand Rounds 2

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Presentor: John Hommer E. Dy M.D.Moderator: Joy Marchadesch M.D


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To discuss Acute Coronary Syndrome itsetiology, pathogenesis, diagnosis, treatment and

prevention


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B.R, Female, 66yo

widowed

Roman Catholic Housewife

From Legazpi City


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Chest Pain


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admission

1 week

On and off retro sternal sharp chestpain

Easy fatigability

Few

hours

Chest tightness

Diaphoreses

Difficulty of breathing

Vomiting


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General: No recent weight change, (+) bodyweakness, (-) fever

Skin: No rashes or pruritus

HEENT: No headache, no blurring of vision, nodifficulty of swallowing

Respiratory: No cough

Cardiovascular: no palpitations

Extremities: Bipedal edema


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HPN unrecalled duration, unrecalled medicationwith poor compliance

Non-DM

No previous Hospitalization No history of any surgical operation

No allergy to food and drugs


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(+) HPN mother, siblings

(-) DM

(-) Cancer

(-) bronchial asthma (-) heart disease


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Non - smoker

Non- alcoholic drinker


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General Survey: Conscious Coherent

Diaphoretic

In cardio-respiratory distress


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Vital Signs

BP: 70/50 mmHgCR: 52 bpmRR: 25 cpm

Temp: 36oC

Weight: 51kg

Height: 54BMI: 23O2 sat : 97-98%


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Skin: Afebrile Good skin turgor Cold to touch

HEENT: Pink palpebral conjunctiva anicteric sclerae

no naso-aural discharge, no tonsillo-pharyngeal congestion


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Neck:

No cervical lymphadenopathies

no mass

(+) neck vein engorgement Chest/Lungs:

Symmetrical chest expansion

(+) retractions subcostal Bibasal crackles


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Heart:Adynamic precordium,Apex beat at 5th left ICS, AAL,Bradycardic, regular rhythm,no murmur


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Abdomen: flabby Normoactive bowel sounds 8 cm liver span midclavicular line and 5 cm

midsternal (+) epigastric tenderness no guarding and rigidity


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Extrenities:

(+) Bipedal edema grade 1, full and equal pulses


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66year old female

Difficulty of breathing

Chest pain

Diaphoresis Epigastric pain

Engorged neck vein

Bibasal crackles

Bipedal edema


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Acute Coronary Syndrome, CHF, FC II


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Aortic dissection

Pneumothorax GERD

Pulmonary Embolism


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DISEASE ENTITY RULE - IN RULE-OUT

Aortic dissection Chest pain Tearing painMurmurBruitsUnequal pulsesTrop-I:negatiive

Pneumothorax Chest painDypnea

Diminished breathsounds over hemithoraxTrop-I: Negative

GERD Retrosternal chest pain Nausea nd vomitingTrop-I Negative

Pulmonary embolism


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On Admission:

Low salt and low fat diet

Diagnostic: 12 Lead ECG

Troponin I

CXR-PA Na, K, Ca, Mg

Lipid profile, ALT and Creatinine

CBC with PC

Urinalysis IVF w/ D5W

Dopamine drip


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WBC 8.1

Hemoglobin 114

Hematocrit 0.38

Platelet count 145

Neutrophils 59

41 26


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Medication: Fondaparinux 2.5 mg sq, OD

ASA 80 mg 4 tabs Stat chewed then 1 tab OD

Clopidogrel 75mg 4 tabs Stat chewed then 1 tab OD

Atorvastatin 80mg 1 tab @ HS

Lactulose 30cc @ HS


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2nd Hospital day

S> Decrease chest pain, (+) Bipedal edema

O> BP: 90/50 - 120/70 CR: 84 bpm RR: 18cpm

A> Acute Coronary Syndrome, NSTEMI vs UA, CHF,FC II

P> 2D Echo once stable Repeat 12-L ECG Start Trimetazidine 35mg/tab, BID Fondaparinux 2,5 mg SQ OD Furosemide 20 mg IV q8 provided SBP >100mmhg Spironolactone 25 mg tab, OD Lanzoprazole 30 mg tab, OD continue Dopamine drip


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Labs:

Trop I: Positive

Chole: 5.3 mmol/L Trigly: 1.63 mmol/L N HDL: 0.9 mmol/L LDL: 3.67 mmol/L VLDL: 0.7 mmol/L Chol/dHD: 6.18

Urea: 5.4 mmol/L

Crea: 101 umol/L K: 4.1 mmol/L Calcium: 2.54 mmol/L

ALT:


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3rd Hospital day

S> (-) Chest pain , (-) DOB, (+) bipedal edema,grade 1

O> BP: 95/50- 115/64 mmhg CR:80 bpm RR:22

cpm A> Acute Coronary Syndrome, NSTEMI, in SR,

CHF, FC II

P> Continue Dopa drip


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Labs:

Color Yellow

Transparency Sl. turbid

Reaction 6

Specific gravity 1.020

Pus cells 1-2/hpf

RBC 0-1/hpf

Epithelial cells Few

Bacteria Few

Albumin negative

Sugar negative


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4th Hospital day:

S> BP: 90/50 mmhg CR: 60 bpm RR: 25 cpm

O> (-) chest pain, , (-) DOB, bipedal edema

A> Acute Coronary Syndrome, NSTEMI, in SR,CHF, FC II

P> Repeat 12-L ECG

Furosemide @ 20 mg IV q 8hrs


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Magnesium 0.68 N

Na 131 N

K 4.03 N


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5th Hospital day:

S> BP: 140/80 mmhg CR: 65 bpm RR: 23 cpm

O> (-) chest pain, , (-) DOB, bipedal edema

A> Atherosclerotic heart disease, Acute CoronarySyndrome, NSTEMI, in SR, CHF, FC II

P> Continue medication May transfer to cardio ward

shift furosemide IV to 20mg/tab

12-L ECG


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7th Hospital day

A> Acute Coronary Syndrome, NSTEMI, in SR, CHF, FC II

P>Discharged improved THM:

Trimetazedine 350mg, BID

Spironolactone 25mg/tab, tab OD

ASA 80mg/tab, OD

Clopidogrel 75mg/tab, OD

Atorvastatin 80mg/tab, OD HS

Lansoprazole: 300 mg OD x 7 days

Lactulose 30cc OD @ HS


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IHD

CAD(stable angina) ACS

NSTEMI(Trop-I: +)

STEMI

No ST ElevationST Elevation

Unstable Angina

(No ST Elevation ACS)


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Imbalance between myocardial oxygen supply anddemand.

Or by increase in myocardial oxygen demandsuperimposed on an atherosclerotic plaque.


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1. Plaque rupture or erosion w/ superimposednonocclusive thrombus.

2. Dynamic Obstruction

3. Progressive mechanical obstruction

4. 2ndry UA related to increased myocardial oxygendemand and/or decreases supply


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Clinical History/P.E.

Echocardiogram: ST-segment depression > 0.5 mm (0.5 mv)in two or more contigous leads.

Biochemical markers: rise in Troponins occurs after 3 to 4hours. And may persist elevated up to 2 weeks.

Echocardiography

Imaging of the coronary anatomy


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Chest pain Dyspnea

Epigastric dyscomfort

Diaphoresis

Pale cool skin

Sinus tachycardia

Basilar rales

Hypotension


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Grading of Angina Pectoris

According to CCS Classification

Class Description of Stage

I Ordinary physical activity does not cause angina

II Slight limitation of ordinary activity.


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Grading of Angina Pectoris

According to CCS Classification

III Marked limitations of ordinary physical activity.

IV Inability to carry on any physical activity withoutdiscomfort.


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Anti-ischemic agents Anticoagulants

Antiplatelets

Coronary revascularization Long term management


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Medical treatment: Must be placed at bed rest w/continous ECG monitoring for ST-segment deviationand cardiac rhythm.

Oxygen

Anti-ischemic treatment: Nitrates: given sublingually

Anti coagulant: Fondaparinux 2.5 SQ,

Enoxaparin 1 mg/kg subcutaneously q12


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Antiplatelets:

ASA, initial dose of 160-325 mg followed by 75-100mgOD

Clopidogrel, Loading dose of 300-600mg followed by75mg daily.

Fundaparinux:


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pCatalyzes factor Xa inhibition by antithrombin and does notenhance the rate of thrombin inhibition. Is cleared unchanged via kidneys , it is contraindicated in

patients w/ a creatinine clearance of < 30 ml/min.

ASA: antithrombotic effect by irreversely acetylating andinhibiting paltelet cyclooxygenase (COX)1.

Clopidogrel: Antiplatelet The drug irreversibly inhibits the P2Y subtype of ADP receptor,

which is important in aggregation of platelets and cross-linkingby the protein fibrin. The blockade of this receptor inhibitsplatelet aggregation by blocking activation of the glycoproteinIIb/IIIa pathway.

Atorvastatin: inhibit HMG reductase.


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Lactulose: The metabolites of lactulose draw water into the

bowel, causing a cathartic effect through osmotic action.

Trimreazidine: an anti-ischemic metabolic agent, whichimproves myocardial glucose utilization through inhibition

of fatty acid metabolism, also known as fatty acid oxidationmetabolism.

Furisemide: loop diuretic. By inhibiting the transporter, theloop diuretics reduce the reabsorption of NaCl


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Lanzoprazole: Proton pump inhibitor (PPI) whichprevents the stomach from producing gastric acid.

Dopamine: acting on the sympathetic nervous system,producing effects such as increased heartrate and blood pressure.


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Long term management:

Recommendation for lipid lowering therapy: Statins are recommended for all NSTE-ACS patient,

irrespective of cholesterol levels, in the aim of achievingLDLc < 2.6 mmol/L.

Use of beta-blocker BB are appropraite anti-ischemic therapy and may help

decrease triggers for MI.

Use of ACE-inhibitors Recommended for plaque stabilization.


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Recommendation for lipid lowering therapy: Statins are recommended for all NSTE-ACS patient,

irrespective of cholesterol levels, in the aim of achievingLDLc < 2.6 mmol/L.

Use of beta-blocker BB are appropraite anti-ischemic therapy and may help

decrease triggers for MI.

Use of ACE-inhibitors Recommended for plaque stabilization.


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Antiplatelet: therapy, recommended to becombination of aspirin and clopidogrel for at 9-12

months.


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Thank You

Grand Rounds 2

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