Case

examples for
Myocardial
Infarction
DR MAHENDER KUMAR M
ASSISTANT PROFESSOR OF MEDICINE
Normal ECG
Normal ECG

Limb leads Augmented Limb leads Chest leads

STEMI vs NSTEMI
How do patients present?

▪ Patients with typical acute MI usually present with chest pain and may
have prodromal symptoms of fatigue, chest discomfort, or malaise in
the days preceding the event; alternatively, typical ST-elevation MI
(STEMI) may occur suddenly without warning.
▪ The typical chest pain of acute MI usually is intense and unremitting
for 30-60 minutes. It is retrosternal and often radiates up to the neck,
shoulder, and jaws, and down to the left arm. The chest pain is usually
described as a substernal pressure sensation that is also perceived as
squeezing, aching, burning, or even sharp. In some patients, the
symptom is epigastric, with a feeling of indigestion or of fullness and
gas.
▪ In some cases, patients do not recognize the chest pain, have an
unusually high pain threshold, or have a disorder that impairs pain
perception and results in a defective anginal warning system (eg,
diabetes mellitus).
▪ In addition, some patients may have an altered mental status caused by
medications or impaired cerebral perfusion. Elderly patients with
preexisting altered mental status or dementia may have no recollection
of recent symptoms and may have no complaints whatsoever.
Other symptoms?

• Anxiety, commonly described as a

sense of impending doom •Profuse sweating

• Pain or discomfort in areas of the •Shortness of breath

body, including the arms, left •Wheezing
shoulder, back, neck, jaw, or
stomach •Rapid or irregular heart rate
• Lightheadedness, with or without •Fullness, indigestion, or choking
syncope
feeling
• Cough
• Nausea, with or without vomiting
Diagnosis

MI is diagnosed when either of the following criteria are met.

Detection of an increase or decrease in cardiac biomarker values (preferably using
cardiac troponin [cTn]) with at least one value above the 99th percentile of the
upper reference limit (URL) and with at least one of the following findings:
▪ Symptoms of ischemia
▪ New or presumed new significant ST-segment-T wave (ST-T) changes or new left
bundle branch block (LBBB)
▪ Development of pathologic Q waves on the ECG
▪ Imaging evidence of new loss of viable myocardium or a new regional wall
motion abnormality
▪ Identification of an intracoronary thrombus by angiography or autopsy
Initial management

The initial management of the overall management plan for patients with
acute MI has the following aims:
• Restoration of the balance between oxygen supply and demand to
prevent further ischemia.
• Pain relief
• Prevention and treatment of complications
▪ Supplemental oxygen by a mask or nasal cannula is indicated only for
patients who are breathless, hypoxic (oxygen saturation < 90%).
▪ All patients should receive nonenteric-coated chewable aspirin in a dose
of at least 162 to 325 mg.
▪ Nitrates are usually given as a 0.4 mg dose in a sublingual tablet. Maybe
repeated 2 times with 5-minute intervals.
▪ Refractory or severe pain should be treated symptomatically with IV
morphine.
▪ Fibrinolysis by recombinant tPA agents vs Primary percutaneous coronary
intervention (PCI).
 Case 1

▪ Mr. Ramesh was a 60-year-old male, who presented with 8/10 chest pain after
working out. He just quit smoking and started a new workout and diet program
after recently retiring.
▪ He has noticed some chest and shoulder discomfort with working out that
usually resolves with rest, but decided to come to the emergency department
because this episode was unrelenting and more severe.
▪ He described his current pain as severe and sharp, and also complains of nausea
and shortness of breath.
▪ Vital signs are HR: 110 BP: 150/90 RR: 30 Temp 97.6 O2 Sat: 92% on 2L nasal
cannula.
▪ Cardiac troponin was 124 ng/mL
 Case 2

▪ A 57-year-old male lorry driver, presented to his local emergency department with
a 20-minute episode of diaphoresis and chest pain. The chest pain was central,
radiating to the left arm and crushing in nature. On examination he appeared
comfortable and was able to complete sentences fully.
▪ Blood pressure was 180/105 mmHg, heart rate was 83 bpm and regular, oxygen
saturation was 97%.
▪ 30 minutes later the patient’s chest pain returned with greater intensity whilst
waiting in the emergency department. Now, he described the pain as though “an
elephant is sitting on his chest”.
▪ The nurse has already done an ECG by the time you were called to see him.
▪ What is the most likely diagnosis?
▪ What is your next investigation of choice?
▪ What would be the optimal management for this patient?
 Case 3

▪ A 56-year-old man with a past medical history of hypercholesteremia, diabetes

mellitus, no documented family history of cardiac disease, and no home medications
had a syncopal event while at an outdoor recreation facility. After completing a go-
kart racing, the patient sat down and immediately became pale and unconscious.
▪ Owing to bystander concern for cardiac arrest, cardiopulmonary resuscitation (CPR)
without defibrillation was initiated and emergency services were called.
▪ Patient was intubated enroute to hospital. On arrival patient was connected to
ventilator.
▪ Vitals: HR: 45/min, BP: 80/50 mm Hg
▪ You order an ECG on arrival.
What is peculiar in this MI?
LMCA
Wellens Syndrome
Brugada Syndrome
YOUR HEART
THANKS YOU
How confident are you in identifying and
diagnosing MI?

1. Not confident at all

2. Slightly confident
3. Somewhat confident
4. Fairly confident
5. Completely confident