CASE

PRESENTATION
Clinical Profile • CLINICAL PROFILE
• 58 years old
• Male
• Filipino
• Hypertensive (non-compliant to maintenance
medication)
• Smoker (30-pack yr)
• Family History of DM
• HPI:
Substernal chest pain radiating to left
shoulder
• Pertinent negatives:
(-)nausea
(-)vomiting
(-)abdominal pain
(-) fever
Clinical profile
Clinical profile
• Past medical history
Hypertensive Urgency
Impaired Fasting Glucose
• Medications
ISDN (isosorbide dinitrate)
  Telmisartan/amlodipine 40/5 mg 1 tab OD
Carvedilol 6.25 mg 1 tab OD
• Ros
Weight loss of 6kg in 2 months
Diaphoresis
Chest pain and
Palpitations
Numbness of extremities
Polydipsia and Polyuria
 Physical examination
Physical findings General: anxious and restless
 
Vital Signs:
Tachycardic 117
Tachypneic 24
Hypotensive 90/60
  Pale cool skin
Diagnostics
12-L ECG
-Sinus tachycardia, ST-Eevation in Inferior and
Anterolateral wall
hs- Troponin >40,000
Chest x-ray Cardiomegaly

2D-Echo Ejection Fraction- 48%

Hyperglycemia
Hyperlipidemia
Hypercholesterolemia
Hypertrigyceridemia
HbA1c(- 7.4%)
PIVOT

CHEST PAIN
APPROACH TO DIAGNOSIS
APPROACH TO DIAGNOSIS
DIFFERENTIAL
DIAGNOSis
 MYOCARDIAL
I N FA R C T I O N
RULE IN RULE OUT
History: • Cannot totally rule out
Presents with substernal chest pain
persisting for >30 min characterized as
squeezing and with a PRS of 8 to 9 out of 10
anxious and restless
 (+) palpitations
(+) numbness of extremities
polydipsia and polyuria
Physical Exam:
Tachycardic
Tachypneic
Hypotensive
pale, cool skin
BMI: 27.22 kg/m2 (Obese Type 2,
Classification in Asians)
CBG: 247 mg/dl
 Aortic Dissection
RULE IN
• Chest pain that radiates in the
shoulder blades
• Severe, sudden onset often
associated with diaphoresis
• Associated with hypertension
• Peak incidence in the 6th and 7th
decades
• Men are more affected than women
(2:1)
RULE OUT
• No loss of pulses
• No aortic regurgitation
• Neurologic findings are normal
(usually presents with hemiplegia,
and hemianesthesia due to carotid
artery obstruction)
 Pulmonary embolism
RULE IN RULE OUT
 Chest pain that is sudden onset, • Well’s Criteria (low likelihood)
steady and substernal in location (-) dyspnea
 Diaphoresis (-) hemoptysis
(-) prior surgery
 Palpitations
(-) Cancer
 Signs of shock (-) Prior DVT
Hypotension
Tachycardia ● No background of increased clotting
Tachypnea tendency, such as known hereditary
thrombophilia
 Esophageal spasm
RULE IN RULE OUT
• Chest pain  relieved by ● Not meal-related
● Non-exertional
 Duration usually nitroglycerin or
● (-) heartburn
lasts 2-30 min dihydropyridine
● (-) dysphagia
 Closely mimic calcium channel ● (-) regurgitation
angina antagonists
 Gastrointestinal
disorders are the
most common cause
of non-traumatic
chest discomfort
 Admitting Diagnosis

M Y O C A R D I A L I N FA R C T I O N
 PRINCIPLES OF MANAGEMENT

1. Management of ST-Elevation Myocardial Infarction Acute Coronary

Syndrome
2. Management of Hyperglycemia
3. Management of Obesity
Management of ST-Elevation Myocardial Infarction Acute Coronary Syndrome

Principles of Management of STEMI ACS

Begins in the initial evaluation at the ER with 12-Lead ECG and Supporting Laboratory
Evaluation. After proper diagnosis and risk assessment, therapeutic control of discomfort and
subsequent initiation of reperfusion or revascularization is performed if able, or a transfer
strategy is implemented to refer the patient to the nearest hospital capable of performing
reperfusion or revascularization therapy. Then, therapeutic management and supportive care
with subsequent risk stratification with secondary prevention and long-term management is
performed.
Principles of Management of Hyperglycemia

Management is primarily focused on controlling elevated glucose levels and secondary

prevention.

Principles of Management of Obesity

The primary goal of management is to decrease obesity and improve obesity-related

comorbidities and secondary prevention of future comorbidities
 Management of STEMI

1. Initial Evaluation at ER – Targeted History taking and 12-Lead ECG + Laboratory Evaluation

2. Initial Management in the ER

3. Reperfusion Therapy

4. Hospital Management and Secondary Prevention

 Management of STEMI
1. Initial Evaluation at ER – Targeted History taking and 12-Lead ECG + Laboratory Evaluation

Diagnostics Rationale
12-Lead ECG Patients with STEMI require rapid identification and triage
to initiate reperfusion therapy. An ECG should be initiated
as soon as possible in all patients with suspected STEMI. If
there is ST segment elevation of at least 0.1 mV in two
contiguous leads, these patients will benefit from
reperfusion therapy.
 
Right precordial leads should be done in suspected right
ventricular infarction. There are some ECG tracings that
make the diagnosis of AMI difficult, such as LBBB,
ventricular paced rhythm, persistent ischemic symptoms
without diagnostic ST segment elevation, isolated
posterior MI, and ST segment elevation in lead aVR. In
these situations, certain ECG changes are seen, such as
marked ST elevation and hyperacute T waves, and these
require immediate reperfusion therapy.
2.Initial Management in the ER
Therapeutic Management Rationale
Aspirin  Main anti-platelet drug
 160 to 320 mg tab (non-enteric coated,  Maintains patency of infarct-related artery in
chewable) conjunction with reperfusion strategies
 Reduces patient’s tendency to thrombosis
 

P2Y12 Inhibitors  Maintains patency of infarct-related artery in

 Clopidogrel 300 to 600mg (whether or not conjunction with reperfusion strategies
fibrinolysis will be given)  Reduces patient’s tendency to thrombosis
 Clopidogrel 600 mg or Prasugrel 60mg or
Ticagrelor 180mg (when a patient will
undergo PCI)

Nitrates  Symptomatic relief of chest pain

 Isosorbide Dinitrate 5mg SL (Monitor BP, if  Decreases myocardial O2 demand
BP is low, contraindicated)  Increases myocardial O2 supply
Therapeutic Management
Opioids
 Morphine Sulfate 2 to 4 mg IV
with increments of 2 to 8mg IV
repeated at 5 to 15 min intervals
(Monitor BP, may reduce cardiac
output and BP)
O2 Therapy
 Supplemental O2 2-4L/ min via
nasal cannula or face mask (Given
only with hypoxemia SPO2 <90%)
Rationale
 Significant relief of chest pain
 Reduces anxiety and
restlessness – present in patient
 Reduces cardiac metabolic
demand
 To treat hypoxemia if present
3.Reperfusion Therapy

Reperfusion is a primary goal of management in STEMI patients. This should be

administered to all eligible patients with STEMI with symptom onset within the last 12
hours. Reperfusion is reasonable if symptom onset is between 12-24 hours with evidence of
ongoing ischemia.
PCI vs Non-PCI Reperfusion:
Reperfusion Therapy
Percutaneous Coronary Intervention
 Stenting and/or angioplasty without
preceding fibrinolysis – Primary
PCI
Non-PCI: Fibrinolysis
 Tissue plasminogen activator (tPA)
 Streptokinase
 Tenecteplase (TNK)
 Reteplace (rPA)
Rationale
 Effective in restoring perfusion in
STEMI
 Applicable to patients with
contraindications to fibrinolytic therapy
 Preferred when diagnosis is in doubt,
cardiogenic shock is present, bleeding
risk is increased or if symptoms have
been present for 2-3 hours or more
(clot is more mature and less easily
lysed by fibrinolytics)
 Preferred with patients of High Risk
from STEMI
 If PCI is unavailable, fibrinolysis is
performed
 If no contraindications are present, it
is performed
 Restores coronary arterial patency
Disadvantage
 Expensive
 Limited availability – Only
PCI-equipped hospitals
(Level 3 in PH)
 Must be performed by
experienced operators in
dedicated medical centers.
 Must be performed within
30 mins of presentation
(door-to-needle time of
less than or equal to 30
min)
Figure X. Reperfusion Therapy for patients with ST-Segment Elevation Myocardial Infarction
4.Hospital Management and Secondary Prevention
Pharmacotherapeutic Management Rationale
Aspirin 80mg to 100mg/day  Maintain patency of infarct related artery
PO indefinitely  Patients undergoing PCI should receive dual anti-platelet
Antiplatelet and therapy (DAPT) for at least 12 months
Antithrombotic Therapy  
Clopidogrel 75mg/day PO
maintained for 2 weeks
Anticoagulant Therapy  Indicated in Primary PCI patients
 Unfractionated Heparin (UFH)  Prophylaxis for ischemic complications
 LMW Heparin (LMWH; Dalteparin, Nadroparin,  LMWH is more beneficial than UFH due to ease of
Enoxaparin) administration, absence of the need for anticoagulation
 Factor Xa inhibitors (Rivaroxaban, Fondaparinux) monitoring

Beta Blockers  Initiated in the first 24 hours except in signs of:

 Metoprolol tartrate 25-50mg q6-12 PO / IV o Signs of Heart failure
 Carvedilol 6.25 – 25 mg BID PO o Low output state
o Increased risk for cardiogenic shock
 Contraindicated in asthmatic patients
 Results in slowing of heart rate, treatment for tachypnea
and lowering of systemic blood pressure
 May reduce risk of ventricular arrhythmias, which are
important cause of death following AMI
Pharmacotherapeutic Management Rationale
Angiotensin-Converting ACE Inhibitors:  Recommended that an ACEI is given to patients
Enzyme Inhibitors (ACEI) Captopril 6.25-50mg TID SL within 24 hours, unless contraindicated
and Angiotensin Receptor   (hypotension, significant renal failure, intolerance /
Blockers (ARBs) Ramipril 2.5-5mg BID allergies)
     Reduces mortality after STEMI in conjunction with
Aspirin and Beta Blockers
 In the event that there is intolerance of ACEIs, ARBs
AR Blockers: must be given
   Must start in lower doses initially and titrated to
Valsartan 20-160mg BID recommended levels in the absence of adverse
(preferred) reactions.

Antidiabetics  HBA1c Reduction at 1-2%

 Biguanide – Metformin 500mg ER Tablet OD at  Does not cause hypoglycemia
Bedtime  Inexpensive
 Well studied with minimal side-effects
 Decreased risk of cardiovascular events
HMG-CoA Reductase Inhibitors  High intensity statin initiated for
 Atorvastatin 80mg OD hypercholesterolemia and hypertriglyceridemia
 
Supportive Care Aspect Rationale/ Remarks
Activity  First 12 hours: bed rest
 Next 12 hours: Dangling of feet at
bedside and sitting on a chair
 2nd and 3rd hospital day: Ambulation in
the room with increasing duration and
frequency to a goal of 185m (600ft) at
least 3x a day
 2 weeks: possible resumption of work
and sexual activity
Diet NPO or only clear liquids (due to risk of
emesis and aspiration) for the first 4-12
hours after admission
Bowel Movement  Use of stool softeners to prevent
exertion which may increase blood
pressure
Sedation  May be used in patients who require
sedation during hospitalization to
withstand period of enforced inactivity
Non-Pharmacologic Management Rationale/ Remarks
Smoking Cessation  Complete cessation of smoking is
recommended

Physical Activity  30 min. of moderate intensity aerobic

exercise 3 to 4 days per week
 Cardiac rehabilitation recommended

Weight Management  Target BMI 18.5-24.9 kg/m2

 Target waist circumference: women
<35 inches, men <40 inches
HOSPITAL COURSE
• Upon admission, patient presented with chest pain of increasing intensity with a PRS of
8- 9 /10, lasting more than 30 minutes with decreasing interval and increasing frequency
accompanied by anxiety and restlessness. Patient was managed as a case of Acute MI
and was given 300 mg clopidogrel OD. (ASYA NA BA IT MEDS? PAKI CHECK NURSE AND
PHARMA FRIENDS HUHUH SORRY). Stat HsTrop-I was ordered and results showed
marked elevation with value of >40,000ng/L. 1.5M unit IV streptokinase administered
immediately within 30 minutes under close monitoring. ECG tracing showed sinus
tachycardia, normal axis, st-elevation in inferior and anterolateral wall. Cardiomegaly
was also noted on CXR. Lipid profile showed elevated TAG, LDL, VLDL, and Total
cholesterol thus, initiation of 80 mg atorvastatin tab OD. Patient’s Glucose was 7.1
mmol/L with an elevated HbA1c 7.4% and was prescribed with 500 mg Metformin OD.
• On the 1st hospital day, chest pain was reduced now with only a PRS of 5/10. However,
patient had symptoms of vomiting, numbness on extremities and blurring of vision.(pa
help management hadi huhu) CBG ranged 159-232 mg/dL though there were no
symptoms of polyuria nor polydipsia under continued medication with 500 mg
Metformin OD. 2D echo with ejection fraction 48% showing concentric LVH with
multi-segmental wall motion abnormality with depressed left ventricular systolic
function and Doppler evidence of grade 2 diastolic dysfunction indicating gradual
recovery.
• On the 2nd hospital day, remarkable reduction of chest pain with PRS of 2-3/10 only
upon exertion, no fever, nausea, nor vomiting noted. BP 120/70, afebrile at 36.2C, RR
20 cpm, HR 88 bpm, 98% O2 RT indicative of stabilizing condition. CBG 100-116
mg/dL well controlled. Patient was advised for discharge with the following take home
medications
 PROBLEM LIST
1. S-T Segment Elevation Myocardial Infarction (STEMI)

2. Hyperglycemia

3. Hypertriglyceridemia
PROGRESS NOTES
 Date & Time Problem Subjective Objective
September 10, S-T Segment Elevation Still with chest pain, PRS Chest x-ray Cardiomegaly
2020 Myocardial Infarction 5/10, no diaphoresis, no  2D-ECHO EJECTION FRACTION-
  (STEMI) fever, nausea, vomiting. 48%.
10:00 pm    Concentric left
(+) Blurring of vision ventricular hypertrophy
with multi-segmental
wall motion abnormality
with depressed left
ventricular systolic
function with Doppler
evidence of grade 2
diastolic dysfunction.
 Mild atrial regurgitation
 Trivial tricuspid
regurgitation
 Small pericardial effusion
w/o signs of tamponade
 
ECG:SINUS
TACHYCARDIA,
NORMAL AXIS, ST-
ELEVATION IN
INFERIOR AND
ANTEROLATERAL WALL
VS:
- BP: 120/80mmHg
- T: 36.0 C
- RR: 20 CPM
- HR: 108 BPM
- O2 Sat: 98%
UO: 1.5 cc/kg/hr
Assessment Plan
Improving STEMI, Monitor chest pain
decreased chest pain, Monitor vital signs every 6-8 hours
controlled blood  
pressure, Medications:
Improved palpitations, no Continue:
breathing problems. - Aspirin 80mg chewable tab
OD PO
- ISDN 5mg SL as needed
Shift
- Clopidgrel 300mg to 80mg
OD PO
Start
- Metoprolol 50mg BID
- Captopril 6.25mg TID PO
Discontinue
- Morphine sulfate 2-4mg IV
Supportive
- Advise bed rest for first 12
hours
- NPO or clear liquids only to
prevent emesis and aspiration
for first 4-12 hours
 
 Date & Problem Subjective Objective Assessment Plan
Time
September Hyperglycemia No polyuria, blurring of vision CBG levels Monitor CBG range daily
10, 2020 polydipsia, with VS: decreased, Monitor daily Urine Output
  unintentional 120/80, Hyperglycemia  
10:00 pm weight loss. 36.0 C, slightly improved, Medication:
  20 cpm, urine output slightly Continue
(+) Numbness of 108 bpm, high - Metformin 500mg ER
extremities 98% O2   Tab OD HS
  CBG range- 159-232 HbA­­1C –above  
  mg/dL normal Supportive:
  UO- 1.5 cc/kg/hr   - Give clear liquid diet
  Improving - Calculate for daily
HbA1C – 7.4% hyperglycemia caloric intake to
  facilitate diet
   

September Hypertriglyceridemia Unremarkable VS: Improving blood Start monitoring lipid panel
10, 2020 120/80, pressure control every 24 hours
  36.0 C,    
10:00 pm 20 cpm, Medication
108 bpm, Start
98% O2 - Atorvastatin 80mg tab
OD HS
Date & Time Problem Subjective Objective Assessment Plan

September S-T Segment Chest pain upon VS Improving Continue monitoring

11, 2020 Elevation STEMI exertion PRS 2-3/10, BP – 120/70 mmHg   vital signs
12nn no fever, no vomiting T – 36.2 C Improving chest  
RR – 20 CPM pains, improving Continue medications
HR – 88 BPM vital signs.  
Supportive
O2 Sat – 98% - Start giving diet
BP controlled, HR consisting of daily
normalized, RR caloric needs PO
normalized

 September Hyperglycemia Unremarkable CBG: 100-116 mg/dL Improving Continue monitoring

11, 2020 UO: 1.2 cc/kg/hr hyperglycemia CBG
12nn   Continue monitoring UO
CBG further Continue Medicaitons
improved  
Supportive
  - Start giving diet
UO normalized consisting of daily
caloric needs PO
- Avoid high sugar
food, give complex
carbohydrates
Date & Problem Subjective Objective Assessment Plan
Time
September
11, 2020
Hypertriglyce Unremarkable Unremarkable Improved Continue
12nn ridemia BP – 120/70 blood monitoring
mmHg pressure lipid panel
control
DRUG STUDY
 Generic Name Brand Name Mechanism of Indication Contraindicatio Dose and Adverse Effects
Action n Frequency

Aspirin Aspilets Aspirin inhibits For reducing the Hypersensitivity 2 tab once, Increased
Chewable platelet risk of mortality in to aspirin and loading dose bleeding
aggregation by patients with a other salicylates 160 mg tendencies
blocking suspected acute      
thromboxane A2 myocardial Presence of 1 tab OD/ day May increase
synthesis in infarction acute GI ulcer maintenance risk of renal
platelets. Its     dose indefinitely failure
mechanism of For reducing the Severe Heart (80mg/day)  
action is based on risk of morbidity Failure   May increase
irreversible and mortality in     risk of GI ulcers
inhibition of cyclo- patients with Severe Renal  
oxygenase (COX-1). previous and Hepatic  
myocardial Failure
infarction
Maintains patency
of infarct-related
artery
 
Reduce tendency
to thrombosis
 Generic Brand Mechanism of Indication Contraindicatio Dose and Adverse Effects
Name Name Action n Frequency

Clopidogrel Platexan Prodrug For Acute Hypersensitiviti 300 mg Increased

activated in Coronary es (rare) loading dose bleeding
vivo. Active syndrome,   (4 tabs once) tendencies
metabolite conjunct with Intake before followed by
inhibits P2Y12 aspirin. surgery 75mg OD for
subtype of ADP   2 weeks
receptor, which Maintains patency Hepatic
is important in of infact-related impairment 1 tab / day /
activation of artery 2 weeks
platelets and  
eventual cross Reduces tendency
linking of fibrin. to thrombosis
 Generic Brand Mechanism of Indication Contraindication Dose and Adverse
Name Name Action Frequency Effects
Isosorbide Isordil Source of nitric Management of Aortic or mitral 5mg SL tab Orthostatic
Dinitrate oxide which angina pectoris stenosis, marked as needed hypotension
anaemia, cardiac
stimulates and symptomatic tamponade,
 
cGMP, relaxing relief of chest hypertrophic Dizziness,
vascular pain cardiomyopathy, headache,
smooth hypotension, syncope
muscles. It hypovolaemia,  
decreases left raised intracranial Tachycardia,
pressure.
ventricular Concomitant use of
rebound
pressure a hypertension
(preload) and phosphodiesterase , rebound
arterial 5 (PDE5) inhibitors angina,
resistance and riociguat. paradoxical
(afterload). bradycardia
 Generic Brand Name Mechanism of Indication Contraindicatio Dose and Adverse Effects
Name Action n Frequency
Morphine Sulfate Hospira It binds to opiate Significant relief of Severe renal 2 – 8 mg IV Physical and
Morphine receptors in the CNS chest pain impairment, dose repeated at 5 to psychological
altering pain   adjustments 15 min intervals. dependence
perception and Reduction of anxiety required  
response by and restlessness   CNS depression,
modulating the   Severe hepatic orthostatic
descending Reduction of cardiac impairment, dose hypotension, severe
inhibitory pathways metabolic demand adjustments hypotension,
from the brain. required syncope
Analgesia, euphoria   constipation.
and dependence are Hypersensitivity
thought to be due to Respiratory
its action at the µ-1 depression,
receptors while circulatory schock,
respiratory heart failure
depression and secondary to
inhibition of chronic lung disease
intestinal
movements are due
to action at the µ-2
receptors. Spinal
analgesia is
mediated by
morphine agonist
action at the κ
receptor.
 Generic Brand Mechanism of Indication Contraindica Dose and Adverse
Name Name Action tion Frequency Effects
Metoprolol Cardiosel Metoprolol is a Decreases mortality Asthma 50mg tab Hypotensio
tartrate beta- rate in patients with   BID PO n
adrenergic suspected or Use with  
receptor confirmed caution in Arterial
blocking agent myocardial patients with insufficiency
which acts infarction. impaired  
preferentially   hepatic Claudication
on beta1 This effect is due to a failuire Edema
adrenoceptors, decreased incidence    
mainly located of severe ventricular Discontinue  
in cardiac arrhythmias and when there is
muscle causing limitation of infarct significant
a size. Metoprolol has hypotension
sympatholytic also been shown to
action. decrease the
incidence of non-
fatal myocardial
reinfarction.
 Generic Brand Mechanism of Indication Contraindicati Dose and Adverse
Name Name Action on Frequency Effects
Captopril Capotec Captopril is a Reduce Hypotension, 6.25mg tab Hypotension,
sulfhydryl- mortality after singnificant TID PO intestinal or
containing ACE STEMI in renal failure, peripheral
inhibitor which conjunction angioedema,
competitively with Aspirin non-
inhibits ACE to and Beta productive and
prevent Blockers persistent
conversion of Blood pressure cough;
angiotensin I to control cholestatic
angiotensin II,   jaundice,
thereby proteinuria,
increasing neutropenia,
plasma renin agranulocytosi
activity and s,
reducing thrombocytop
aldosterone enia, renal
secretion. impairment or
failure and
hyperkalaemia
Generic Name Brand Name Mechanism of Action Indication Contraindication Dose and Adverse Effects
Frequency

Metformin Glumet XR Metformin is a HBA1c Renal 500mg ER Mild to

biguanide
antihyperglycaemic
Reduction at 1- impairment. Tab OD HS moderate
agent which improves 2% eGFR 30- renal
glucose tolerance by   44mL/min impairment,
lowering both basal and Decreases risk
postprandial plasma of CV events
  hepatic
glucose. It decreases impairment
hepatic glucose  
production by inhibiting
gluconeogenesis and Vitamin B12
glycogenolysis, delays deficiency
intestinal glucose
absorption, and
improves insulin
sensitivity by enhancing
peripheral glucose
uptake and utilisation.
 Generic Brand Mechanism of Action Indication Contraindicatio Dose and Adverse Effects
Name Name n Frequency
Atorvastatin Lipitor Atorvastatin selectively Treatment for Hypersensitivity, 1 80mg tab Rhabdomyolysis
and competitively inhibits hypercholester active liver OD HS Myopathy
HMG-CoA reductase, the olemia, disease Myalgia
enzyme that catalyses the dyslipidemia Acute renal
conversion of HMG-CoA to   failure
produce mevalonate. The Prophylaxis of Hepatitis
reduction of mevalonate CV events in Hepatic Failure
production results to a high-risk
compensatory increase in patients
the expression of LDL
receptors and stimulation
of LDL catabolism,
consequently lowering
LDL-cholesterol levels.
THANK YOU