CASE PRESENTATION

ACS , NSTEMI , ILWMI

1
 CASE SUMMARY

o
“ACS:NSTEMI”

o “ILWMI”

o “CAG+PCI to LCx/OM”
 SUBJECTIVE

Chief complaints Past medical history Past surgical history

o C/O chest discomfort, tightness o H/O SHTN 7years o Hernioplasty 4 years back
o Breathing difficulty o Irregular RX (outside)

Social history Family history Allergies

o Mother had : DM
o Alcohol – 20 years
o Father : Death due to cardiac o NKDA
o Cigarette – 15 years
arrest
 OBJECTIVE

A.

o
B. Systemic Examination:

TEST DATE IMPRESSION

o LVH with secondary

repolarization abnormality
o Normal P axis
Electrocardiogram ECG 27.1.23 (Pre - PCI) o Anterior ST elevation
(probably due to LVH)
o Prolonged QT interval

o Normal P axis
o Probable left ventricular
Electrocardiogram ECG 27.1.23 (Post - PCI) hypertrophy
o Multi LVH criteria
o Non-specific ST abnormality
 TEST DATE IMPRESSION

o Abnormal T wave (considered

Electrocardiogram ECG 28.1.23 4:41am to be ischemia)

o Mild and basal inferior ,

posterior and lateral wall
hypokinetic
o Mild to moderate LV
dysfunction
o Grade 1 LVDD
Echocardiogram ECHO 29.1.23
o Mild MR
o NO PAH/PE/clot
o RA , RV, IVC - Normal
o Dilated LV cavity
o EF: 40-45%
 DATE 27.1.23 28.1.23

TIME 11am 7.40pm 6am 9.30am 3pm 9pm

TEMPERATURE
•Fahrenheit 98.6 97.6 98.2 97.8 98.1 98.3

HEART RATE
72 62 82 84 80 83
b/m

RESPIRATORY
20 22 20 20 20 20
RATE b/m

BP mmHg 110/70 170/100 130/70 110/70 110/70 150/90

SpO2 % 97 99 96 98 97 95
 DATE 29.1.23 30.1.23

TIME 6am 9am 3pm 9pm 6am 10am

TEMPERATURE
•Fahrenheit 97.6 98.1 97.8 98.5 98.2 98.2

HEART RATE
76 76 80 84 66 66
b/m
RESPIRATORY
20 20 20 20 20 20
RATE b/m

BP mmHg 140/90 130/70 130/80 120/70 140/90 130/70

SpO2 95 97 97 96 97 97
 DATE 27.1.23
Hemoglobin Hb
13.5 g/dL
(13.8 - 17.2 g/dL)
Total count TC
5500 cells/cumm
(4400 - 11,300 cells/cumm)
Differential count DC
P (45 - 75%) 62%
L (20 - 40%) 34%
E (2 - 6%) 01%
B (upto 1%) 00%
M (2 -10%) 03%
Total RBC (4 - 5.1 million cells/mm3) 4.47 million cells/mm3

PCV (35 - 47%) 38.6%

MCV (80 - 96 µm3) 86.4µm3

 DATE 27.1.23

MCH (27 - 34 pg/cell) 30.2 pg/cell

MCHC (31 - 36 g/dL) 35 g/dL

Platelet (150,000 - 450,000 platelets/mcL) 2,43,000 platelets/mcL of blood

Urea (10 - 50 mg/dL) 26 mg/dL

Sodium serum (132 - 146 mEq/L) 141 mEq/L

RDW (11.5 - 14.5%) 14.7%

 DATE 28.1.23

Fasting blood sugar FBS (70 - 100mg/dL) 93 mg/dL

HIV & HCV Negative

DATE 27.1.23 28.1.23 29.1.23

Creatinine
0.8 mg/dL 0.7 mg/dL 0.8 mg/dL
(0.5 - 0.9 mg/dL)
Potassium K
3.8 mEq/L 3.4 mEq/L 3.6 mEq/L
(3.7 - 5.4 mEq/L)
 ASSESSMENT

❖ Problem 1:
o
ACS:NSTEMI.

o Patient underwent a surgical procedure “ CAG+PCI LCx/OM”.

o For better progress and further prevention patient was prescribed with antiplatelets, beta
blockers, statin, thrombolytics.

o The drugs provided were Tab. Brilinta 90mg, Tab. Ecospirin 75mg, Tab. Tonact 80mg,

Tab. Betaloc 25mg.

❖ Problem 2:
o management
ILWMI.

o Patient should be advised to follow a long - term therapy with anti platelets, beta
blockers and high intensity - high potency statins.

❖ Problem 3:
o Hypertension

o
❖ Assessment of current status:

NOT WELL ACUTE

DIAGNOSIS STABLE ON THERAPY
CONTROLLED MONITORING

ACS:NSTEMI - - - yes

ILWMI - - - yes

Hypertension - - yes yes

 PLAN
A.

DIAGNOSIS GOAL OF TREATMENT

o To improve blood flow

o Treating current complication i.e., by
ACS:NSTEMI
performing PCI on LCx/OM
o To prevent further blockages
o Improve blood flow to the heart muscle
ILWMI o Medications should be recommend based on the
individual severity
o To normalize pressure.
Hypertension o To prevent or to arrest cardiovascular damage
Current drug regimen:

START
S.NO NAME OF DRUG DOSE FREQUENCY ROUTE
DATE

Tab. Brilinta
1 90mg BD Oral 27.1.23
TICAGRELOR

Tab. Ecospirin 27.1.23

2 75mg OD Oral
ASPRIN

Tab. Tonact
3 80mg HS Oral 27.1.23
ATORVASTATIN

Tab. Flavedon MR
4 35mg BD Oral 27.1.22
TRIMETAZIDINE HCL

Tab. Repace
5 25mg BD Oral 27.1.22
LOSARTAN POTASSIUM
 START
S.NO NAME OF DRUG DOSE FREQUENCY ROUTE
DATE

Tab. Rantac
6 120mg BD Oral 27.1.23
RAITIDINE

Tab. Trika
7 0.5mg HS Oral 27.1.23
ALPRAZOLAM

Tab. Amlogard
8 5mg BD Oral 27.1.23
AMLODIPINE RESILATE

Tab. Betaloc
9 25mg BD Oral 27.1.23
METOPROLOL

Syp. Potklor
10 15ml TDS Oral 28.1.23
POTASSIUM CHLORIDE

Tab. Telista
11 40mg BD Oral 29.1.23
TELMISARTAN
C. Drug treatment plan:
❖ Indication:

CHOICE OF DRUG INDICATION

o Reduce the rate of cardiovascular death, MI and

Tab. Brilinta - 90mg
stroke in patients with ACS.

o Used to treat and prevent heart attacks, stroke

Tab. Ecosprin - 75mg and heart related chest pain
o Prevent formation of clot in blood

Tab. Tonact - 80mg o Used to lower cholesterol and triglycerides

o Used in treatment of angina

Tab. Flavedon MR - 35mg o It prevents new attacks of angina but does not
stop an acute attack once it started

Tab. Repace - 25mg o Used to treat high blood pressure

DRUG OF CHOICE INDICATIONS

o Used to treat and prevent heart burn,

Tab. Rantac - 150mg indigestion including stomach ulcers and reflux
diseases.
o Treats anxiety, alters brain activity calms it and
Tab. Trika - 0.5mg
provides relief.

o Helps in reduction of hypertension and heart’s

Tab. Amlogard - 5mg
work-load

o Lowers hypertension
Tab. Betaloc - 25mg
o Treat and prevent heart attacks

o Treatment and prevention of low level of

Syp. Potklor -15ml
potassium (hypokalemia)

o Used to treat high B.P

Tab. Telista – 40mg
o Prevent future heart attacks and strokes
❖ Safety:

DRUG SAFETY ADVICE

o Caution is advised while consuming alcohol

Tab. Brilinta - 90mg with brilinta 90mg.
o Caution is needed in patients with liver diseases.

o Its unsafe to consume alcohol along with

ecosprin.
o Ecosprin may decrease alertness and affect your
Tab. Ecospirin - 75mg vision/ make you sleepy. If any of these
symptoms occur, its unsafe to drive.
o Caution is needed in patients with kidney and
liver diseases.
o Its highly unsafe to use during pregnancy and
Tab. Tonact - 80mg
breast feeding.
o Its unsafe as it may cause excessive drowsiness
Tab. Flavedon MR - 35mg
with alcohol.
 DRUG SAFETY ADVICE
o Caution is advised while consuming alcohol with
Tab. Repace - 25mg Tab. Repace 25mg.
o Caution is needed in patients with liver diseases.
o Caution is required in patients with kidney and
Tab. Rantac - 150mg
liver problems.
o Its unsafe to consume it while driving as it could
Tab. Trika - 0.5mg
disturb your vision and alertness.
o Amlogard 5mg may cause side effects that could
disturb the ability to concentrate while driving,
Tab. Amlogard - 5mg so its unsafe to consume and drive.
o Caution is required on patients with liver
diseases.
o Safe to used in patients with liver and kidney
Tab. Betaloc - 25mg
diseases.
o Its unsafe for patients who’re breast feeding and
Tab. Telista - 40mg
in pregnancy.
❖ Efficacy:

❖ Adherence:

o
 INTERACTING
NAME OF DRUG MOA OF DRUG CATEGORY MANAGEMENT
DRUG

Long term (>1wk)

NSAID use
a) NSAID Pharmacodynamic
a) Asprin b) Metoprolol decreases
b) Beta-blocker antagonist
prostaglandin
synthesis
As both the drugs
should be consumed
together, if the
a) NSAID Combination maintenance dose
a) Asprin b) Ticagrelor of asprin is above
b) Anti platelet therapy
100mg it decreases
the effectiveness of
ticagrelor
NAME OF TEST TARGET VALUE FREQUENCY

o cTnI: 0-0.04 ng/mL Blood test once in every three

Troponin test
o cTnT: 0-0.01 ng/mL months

Blood test once in every three

RDW 11.5 - 14.5%
months

Blood test once in every three

Potassium 3.7 - 5.4 mEq/L
months

Hypertension </= 120/80 mmHg Once in every day

❖ Medicines:
o Take your medicine exactly as told, at the same time every day.

❖ Eating and drinking:

o Eat a heart-healthy diet that includes whole grains, fruits and vegetables, lean proteins, and low -fat
or non-fat dairy products.

o Limit how much salt (sodium) you eat as told by your health care provider.

o Use healthy cooking methods such as, grilling, broiling, baking, poaching, steaming, or stir-frying.

o Work with a dietitian to follow a heart-healthy eating plan.


❖ Lifestyle:
o Do not use any products that contain nicotine or tobacco. Products such as cigarettes, chewing
tobacco, and vaping devices, such as e -cigarettes.

o Do not drink alcohol, If you drink alcohol; Limit how much you have to.

o Maintain a healthy weight.

❖ General instructions:
o Tell all the health care providers who provide care for you, about your heart condition; including
your dentist. This may affect the medicines or treatment you receive.

o Manage any other health conditions you have, such as hypertension or diabetes. These conditions
affect your heart.

o Pay attention to your mental health. You may be at higher risk for depression.

o If directed, monitor your blood pressure at home.