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1st

Clinico-pathological conference
Final Year MBBS
27th February, 2015

Myocardial
Presentation by infarction
1605- Abubakkar
Raheel
1622- Haider Ali
1606- Ahmed Arsalan
Long Case

Muhammad Shareef, a 65 year old male patient from


Abbottabad, known case of Diabetes since last 12
years and Coronary Artery Disease for the last 2
years presented in King Abdullah Teaching Hospital
with the complaints of Chest pain and breathlessness
for the last 6 hours. Patient had an episode of
vomiting. He was conscious and well oriented.
Overall health state was weak and meagre.

Dept of Medicine
Frontier Medical and Dental College
Dept of Medicine
Frontier Medical and Dental College
Dept of Medicine
Frontier Medical and Dental College
History of Patient
Name: Muhammad Shareef
Sex: Male
Age: 65 years
Marital Status: Married
Occupation: Retired Govt. servant
Address: Abbottabad
D.O.A: 20th February, 2015
T.O.A: 9:30 am
M.O.A: OPD

Dept of Medicine
Frontier Medical and Dental College
Chief Complaints
Chest pain 6 hrs
Shortness of Breath 6 hrs
Vomiting - 5 hrs

Dept of Medicine
Frontier Medical and Dental College
History of Present illness
Known case of Diabetes - 12 yrs &
Ischemic Heart Disease 2 yrs
Chest pain started 6 hrs back
Sudden in onset
Retrosternal
Crushing in nature
Radiating to left arm, back and neck
Aggravated on exertion

Dept of Medicine
Frontier Medical and Dental College
History of Present illness
Shortness of breath 6hrs
Sudden onset
present at rest
Vomiting 5hrs
2 episodes of vomiting
Vomitus was yellowish

Dept of Medicine
Frontier Medical and Dental College
History of Present illness
Associated symptoms:
Moderate fever
Sweating
Dizziness
Patient was completely conscious
Palpitations

Dept of Medicine
Frontier Medical and Dental College
History of Present illness
Systemic Inquiry
1. General
a. Reduced apetite
b. Sleep disturbed
c. Weakness
2. Respiration
Cough, wheezing and hemoptysis not
present

Dept of Medicine
Frontier Medical and Dental College
History of Present illness
Alimentary system: Nausea & Vomiting
present
Urinary system: No significant history

Dept of Medicine
Frontier Medical and Dental College
History of Past illness
Past Medical History
Diabetes : 12 yrs
IHD : 2 yrs
HTN : Positive
TB : Negative
Asthma : Negative
Past Surgical History
No significant past surgical history

Dept of Medicine
Frontier Medical and Dental College
Family History
Positive for IHD, HTN and DM
2 brothers died of MI

Dept of Medicine
Frontier Medical and Dental College
Drug & treatment History
Patient was taking anti diabetics and anti
hypertensive drugs
Drug compliance was poor
No other significant drug history

Dept of Medicine
Frontier Medical and Dental College
Personal History
Chronic Smoker
No history of drinking
Sedentary lifestyle

Dept of Medicine
Frontier Medical and Dental College
Socio-economic History
Satisfactory

Dept of Medicine
Frontier Medical and Dental College
History based Differential Diagnosis
Acute Myocardial Infarction
Unstable Angina
Pleurisy
Pericarditis
Pneumothorax
Pulmonary embolism
Reflex Esophagitis

Dept of Medicine
Frontier Medical and Dental College
General Physical Examination
Patients general appearance
Pale and anxious

Dept of Medicine
Frontier Medical and Dental College
General Physical Examination

Vitals
B.P: 160/90mmHg in lying position
Pulse: 115 b/m, regular, tachycardia
Temp: 101 F
Resp: 30/m

Dept of Medicine
Frontier Medical and Dental College
General Physical Examination
No Clubbing, pallor, splinter
hemorrhages koilonychias or leconichia
Mild tobacco staining observed
Xanthomas present on extensor
surface of hands
Carotid pulse: thin
JVP: Not raised
Eyes: Anemia not present

Dept of Medicine
Frontier Medical and Dental College
General Physical Examination
Jaundice not present
Dental hygiene good
Carotid briut not audible
No abnormality on fundoscopy
No abnormality seen on thyroid
examination
Lymph nodes not palpable
Pedal and Sacral edema absent
No other significant findings
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Frontier Medical and Dental College
Systemic Examination
1. CVS Systemic Examination
a. Inspection:
No Chest deformity
No sternotomy or any other surgical
scar

b. Palpation:
Apex beat: Lateralized from mid
clavicular line at 6th intercoastal spacece
due to LVH
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Frontier Medical and Dental College
General Physical Examination
Heave: well sustained (at apex)
No left parasternal lift

c. Auscultation:
Mitral, Tricuspid, Aortic, Pulmonary

Dept of Medicine
Frontier Medical and Dental College
General Physical Examination
S1- Normal (Apex)
S2- Audible (Left sternal edge)
No added sounds
No murmurs

Dept of Medicine
Frontier Medical and Dental College
General Physical Examination
c. GIT:
Liver not palpable
Spleen not palpable
Ascites not present

d. Respiration:
Chest clear
No tracheal shift
No remarkable findings

Dept of Medicine
Frontier Medical and Dental College
General Physical Examination

e. CNS:
No remarkable findings

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Frontier Medical and Dental College
Examination based Differential Diagnosis
Myocardial Infarction
Unstable Angina

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Frontier Medical and Dental College
Investigations - ECG

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Frontier Medical and Dental College
Investigations
ECG:

Done within 25 mins of patient arrival


Findings:

Rate: 78.9
Rhythm: Sinus Rhythm

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Frontier Medical and Dental College
Investigations
Leads showing ECG Changes:

V1 to V6, AvL
Changes include:
ST Segment Elevation
Q wave development
Loss of R Wave
T wave inversion

Dept of Medicine
Frontier Medical and Dental College
Investigations
Left Axis deviation seen by thumb rule on
Lead 1 and AvF

(For inferior wall MI, changes are seen in:


Leads 2, 3 and AvF)

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Frontier Medical and Dental College
Investigations
Cardiac biomarkers
Trop T raised
CK-MB raised

Chest Xray
Cardiothoracic ratio increased showing LV
Dilatation
Pulmonary edema not evident

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Frontier Medical and Dental College
Investigations Xray

Dept of Medicine
Frontier Medical and Dental College
Investigations
Other Blood Tests
ESR and CRP raised

Echocardiography could not be done due


to the non availablity of facility.

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Frontier Medical and Dental College
Investigations based Diagnosis

Anterolateral ST Segment Elevation


Myocardial Infarction with Left Axis
Deviation

Dept of Medicine
Frontier Medical and Dental College
Management

Patient was immediately admitted in ICU. Within 10


mins, ECG was performed and based upon
diagnosis, following treatment was given.

Oxygen + Cardiac rhythm monitoring

Dept of Medicine
Frontier Medical and Dental College
Management
Aspirin 300mg PO
(Therapy should be continued indefinitely if there
are no side affects)
Clopidogrel 600mg PO followed by 150mg daily for
1 week and 75mg daily thereafter.
Streptokinase 1.5ml I.V in 100ml sol at 6ml/hr
Inj Morphine
Inj Metoclopromide I.V Stat

Dept of Medicine
Frontier Medical and Dental College
Late Management
Patient advised on the following:
Lifestyle Modification:
Lipid Lowering diet
Cessation of Smoking
Regular exercise

Dept of Medicine
Frontier Medical and Dental College
Late Management
Secondary Drug therapy:
Aspirin
B blocker
Ace Inhibitor/ARB
Statin
Additional therapy for DM and HTN

Dept of Medicine
Frontier Medical and Dental College
The patient was given Streptokinase (Thrombolysis)
within 8 hours of his arrival. He is still in the ICU
undergoing 24/7 observation and treatment. He
was advised angiography due to the unavailability of
the facility at the Hospital. We wish him a speedy
recovery.

Dept of Medicine
Frontier Medical and Dental College
What is MI ?
Detection of rise and/or fall of cardiac biomarker
values (preferably cardiac troponin) with atleast one
of the following:
Symptoms of Ischemia
Significant ST segment-T wave changes or new LBBB
Development of pathological Q waves
Imaging evidence of new loss of viable myocardium
Angiographic identification of Intra coronary
thrombus

Dept of Medicine
Frontier Medical and Dental College
Types of MI
On the basis of ECG, there are two main types of MI
STEMI (major coronary artery complete obstruction)
Non-STEMI (Complete occlusion of a minor vessel or
partial occlusion of a major coronary vessel

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Frontier Medical and Dental College
Arterial Supply of the Heart

Dept of Medicine
Frontier Medical and Dental College
Arterial Supply of the Heart

Dept of Medicine
Frontier Medical and Dental College
Arterial Supply of the Heart
There are two major arteries which supply the heart
Left coronary artery
Right coronary artery

1. Left Coronary Artery:


It is further divided into two main branches:
LAD (I/V septum, Ant. Wall of LV and Apex)
LCx (Lateral, Posterior and Inferior Walls)

Dept of Medicine
Frontier Medical and Dental College
Arterial Supply of the Heart
2. Right Coronary Artery
It supplies RA, RV and inferio-posterior part of LV

Branches include:
PDA (supplies I/V septum inferior part) In 90%
individuals PDA is a branch of RCA. (Right Dominant
people)
In 10% individuals PDA is a branch of LCA (Left
Dominant)

Dept of Medicine
Frontier Medical and Dental College
Arterial Supply of SA & AV Node
SA Node: RCA in 60% individuals
AV Node: RCA in 90% individuals

Clinical Significance:
Proximal RCA occlusion may result in Sinus
Bradycardia and may also cause AV Nodal block
Abrupt occlusion of RCA may lead to infarction of
inferior part of LV

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Frontier Medical and Dental College
Conducting system of Heart

Dept of Medicine
Frontier Medical and Dental College
Nerve Supply of Heart
Adrenergic Nerves from the Cervical Sympathetic
chain supply atria and ventricles
Parasympathetic: Vagus nerve

Dept of Medicine
Frontier Medical and Dental College
Pathophysiology of MI
Atheromatous plaque formation

Interplaque haemorrhages

Exposure of Subendothelial
collagen fibers

Formation of micro thrombi vasospasm

Full blown thrombus

Dept of Medicine
Frontier Medical and Dental College
Pathophysiology of MI

Dept of Medicine
Frontier Medical and Dental College
Pathophysiology of MI

Dept of Medicine
Frontier Medical and Dental College
Pathophysiology of MI
LCA Occlusion:
LAD occlusion (40-50) leads to
Anterior wall infarction of LV
Anterior portion of ventricular septum
Apex
LCx Occlusion 15-20%
Lateral wall of LV

Dept of Medicine
Frontier Medical and Dental College
Pathophysiology of MI

RCA Occlusion (30-40%)

RCA occlusion leads to infarction of


Posterior wall of RV
Inferior wall of LV
Posterior 1/3rd of I/V septum

Dept of Medicine
Frontier Medical and Dental College
Clinical features
Symptoms:
Pain: Crushing, retrosternal chest pain radiating to
back, left arm, neck or jaw
Anxiety and fear of impending death
Nausea and Vomiting
Breathlessness
Diaphoresis

Dept of Medicine
Frontier Medical and Dental College
Clinical features Pain Areas

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Frontier Medical and Dental College
Clinical features
Signs
Sympathetic activation:
- pallor
- sweating
- tachycardia
Vagal activation:
-bradycardia

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Frontier Medical and Dental College
Clinical features
vomiting

Signs of impaired myocardial function:

Hypotention
Narrow pulse pressure
JVP may be raised

Dept of Medicine
Frontier Medical and Dental College
Clinical features
3rd heart sound
Quiet 1st heart sound
Diffuse apical impulse
Lung crepitations

Dept of Medicine
Frontier Medical and Dental College
Clinical features
Signs of tissue damage
fever

Signs of complications e.g Mitral regurgitation,


pericarditis etc

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Frontier Medical and Dental College
Clinical features
Silent MI

diabetic patients
Older individuals

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Frontier Medical and Dental College
Investigations
ECG
Cardiac biomarkers
Chest X-Ray
Echocardiography
ESR & CRP
Angiography

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Frontier Medical and Dental College
Investigations

ECG
It is central to confirming the diagnosis but may be
difficult to interpret if there is bundle branch block
or previous MI. so repeated ECGs are very
important.

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Frontier Medical and Dental College
Investigations Normal ECG

Dept of Medicine
Frontier Medical and Dental College
Investigations Normal ECG

Dept of Medicine
Frontier Medical and Dental College
Investigations - ECG
Earliest changes are seen in ST-segment
1. STEMI
ST-segment elevation
progressive loss of R wave .
Development of Q wave .
Resolution of ST-segment
T-wave inversion

Dept of Medicine
Frontier Medical and Dental College
Investigations - ECG

2. NSTEMI
St-segment depression
T-wave changes
Loss of R-wave
Absence of Q-wave

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Frontier Medical and Dental College
Investigations ECG - STEMI

Dept of Medicine
Frontier Medical and Dental College
Investigations - ECG
Significance of chest leads

Antero-septal infarct
v1 ,v2,v3,v4

Antero-lateral
v4,v5,v6 and AVL and 1

Dept of Medicine
Frontier Medical and Dental College
Investigations - ECG
Inferior infarction
leads II , III and AvF

Posterior wall infarction doesnt cause ST elevation


or Q-waves in the standad leads but can be
diagnosed by the reciprocal changes that is st
depression and a tall R-wave and leads V1-V4.

Dept of Medicine
Frontier Medical and Dental College
Cardiac Biomarkers

1. Troponins
2. Creatinine kinases
3. LDH
4. AST
5. Myoglobins
6. Most specific are troponins and CK-MB

Dept of Medicine
Frontier Medical and Dental College
Cardiac Biomarkers
1. CK-MB
Rises in 4-6 hours and peaks a 12 hours and falls to
normal within 48-72 hours . It is very important.
For diagnosis of recurrent MIs.

2. Troponins: Trop-T and trop-I are gold standards for


diagnosis of MI, Troponins rise in 4 to 6 hours and
remains elevated for 2 weeks

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Frontier Medical and Dental College
Investigations- Chest Xray
Chest Xray to determine cardiomegaly and
pulmonary edema

Dept of Medicine
Frontier Medical and Dental College
Investigations - Echocardiography

Useful for assessing ventricular function and


determining complications

Eg. Mural thrombus, cardiac rupture , VSD and


pericardial effusion etc

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Frontier Medical and Dental College
Investigations - Other blood tests

1. ESR raised
2. Leucocytosis
3. CRP raised

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Frontier Medical and Dental College
Management

Dept of Medicine
Frontier Medical and Dental College
Management

Dept of Medicine
Frontier Medical and Dental College
Drugs used in treatment of MI
1. Analgesics
- Opiates: Morphine Sulphate dimorphine
2. Anti-emetics: metoclopromide
3. Anti-thrombotic drugs
a. Anti platelets: Aspirin
- Clopidogrel
- Ticagrelor
- Gycoprotien 2b and 3a
receptor antagonists: Abciximab
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Frontier Medical and Dental College
Drugs used in treatment of MI
b. Anticoagulants :
LMW Heparin, HMW Heparin,
pentasaccharide - fondaparinux
Warfarin

Dept of Medicine
Frontier Medical and Dental College
Drugs used in treatment of MI
4. Anti anginal drugs
- Nitrates: GTN, isosorbide dinitrate
- B blockers: metoprolol and atenolol
5. Dihydropyridine CCBs:
- Nifedipine, amlodipine
6. Thrombolytics:
- Alteplase, streptokinase, retiplase, tenecteplase

Dept of Medicine
Frontier Medical and Dental College
Invasive modalities used in the treatment of MI
PCI (Percutaneous Intervention)
CABG (Coronary Artery Bypass graft) Surgery

Dept of Medicine
Frontier Medical and Dental College
Late Management of MI
Lifestyle modifications
Diet
Cessation of smoking
Weight control
Reguar exercise

Dept of Medicine
Frontier Medical and Dental College
Late Management of MI- Sec prevention
Anti platelet therapy
B blockers
Ace inhibitors
Statins
Additional therapy for diabetes and HTN control
Mineralocorticoid receptor antagonist
Devices: Implantable Cardiac Defibrillators

Dept of Medicine
Frontier Medical and Dental College
Complications
Arrythmias
Bradycardia
Acute Circulatory failure
Pericarditis

Dept of Medicine
Frontier Medical and Dental College
Complications - Mechanical
Rupture of papillary muscle
Rupture of I/V septum
Rupture of ventricle which can lead to fatal cardiac
temponade
Embolism
Impaired ventricular function, remodeling and
ventricular aneurysm

Dept of Medicine
Frontier Medical and Dental College
Prognosis
If medical care is not provided, death occurs in
almost 1/4th of the cases. Half of the death occurs
within 24nhours of the onset of symptoms and
about 40% of all affected patients die within the
first month.
Patients who reach the hospital and survive
have much better prognosis with a 28 day survival
of more than 85%. The prognosis of anterior
infarcts is worse as compared to inferior infarcts.

Dept of Medicine
Frontier Medical and Dental College
Prognosis

OF THOSE WHO SURVIVE AN ACUTE ATTACK, MORE THAN


80% LIVE FOR A FURTHER YEAR. ABOUT 75% FOR 5 YEARS.
50% FOR 10 YEARS & 25% FOR 20 YEARS.

Dept of Medicine
Frontier Medical and Dental College
Thankyou everyone

Dept of Medicine
Frontier Medical and Dental Collegev