Case Discussion

Acute Coronary
Syndrome
WORKSHOP PERKI 2019
CASE 1
 CASE 1
Eighty-five years old man came to the ER with crushing chest pain since
3 days ago, getting worsen 4-hours PTA, accompanied by cold
sweating. Chest pain was relieved to some extent with ISDN 5mg SL. No
nausea, vomiting, shortness of breath or palpitation. History of stroke (+)
 CASE 1
Vital sign
BP : 104/69mmHg, HR : 61x regular, SaO2: 99% on 2lpm NC, JVP : PR + 2cmH2O
With no abnormality in routine physical examination. BW 70 kg, Height 170 cm.

WHAT IS YOUR INTERPRETATION?

Sinus rhythm, normal axis, rate 61x/min, P wave 0.12 sec, PR interval 0.198 sec, QRS wave 0.08
sec, SV2 + RV5 < 3.5 mV, R/S ratio V1 < 1, T wave inversion V1-V5, QS III, aVF
CONCLUSION sinus rhythm 61 bpm, ischemia anterior, OMI inferior
 CASE 1

DIAGNOSIS?
a.UAP or NSTEMI
b.STEMI Posterior
c.STEMI Anterior Kiilip 1
d.STEMI Anteroseptal Killip 1
e.STEMI Anteroseptal Killip 2
 CASE 1
Immediate care of this patient includes…
a.Loading Dual Antiplatelet
b.Loading Dual Antiplatelet + Anticoagulant
c.Loading Aspirin + Anticoagulant + Anti
ischemia
d.Loading Dual Antiplatelet + Anticoagulant
+ Anti ischemia
e.Loading Dual Antiplatelet + Anticoagulant
+ Anti ischemia + Diuretic
 CASE 1
What will you do next to established your diagnosis?
a.Nothing, patient has STEMI anterior, proceed to
catheterization laboratory
b.Check for cardiac marker to exclude NSTEMI
c.Treadmill stress test, if negative patient could be
treated as an outpatient
d.Order chest X-ray to evaluate another cause of
chest pain
e.Serial ECG
 CASE 1
Cardiac marker result: Troponin 227 pg/ml and CKMB 6.58
pg/ml. What will you do next to decide your next planning to
this patient?
a.Patient had NSTEMI anterior, proceed to catheterization
laboratory
b.Prepare for fibrinolytic therapy if patient had no
contraindication
c. Look for signs of high risk NSTEMI, and stratify the risk of this
patient using TIMI, GRACE and CRUSADE scoring system
d.Do a serial ECG to evaluate whether it will have an
evolution into ST elevation
 CASE 1
The patient had laboratory result as shown below

Complete Blood Count Blood Chemistry

WBC 9.50 10 µ/µL BUN 20.3 mg/dL
HGB 12.81 g/dL SC 1.19 mg/dL
HCT 39.73 % SGOT 20.3 U/L

PLT 232.50 10 µ/µL SGPT 16.50 U/L

Blood glucose 130 mg/dL

Calculate the TIMI, GRACE Na 139

and CRUSADE score! K 4.29
GRACE SCORE
TIMI SCORE
What is the risk classification of this
patient?
A. Very high risk
B. High risk
C. Intermediate risk
D. Low risk
TIMI 4/7, GRACE 162, CRUSADE 41
 CASE 1
You concluded the patient as high risk
NSTEMI, what is your next plan?
a.Immediate-invasive treatment within 2
hours
b.Early invasive treatment within 24 hours
c.Serial cardiac marker and repeat
ECG/continuous ST-segment monitoring
d.Consider non-invasive diagnostic test
 CASE 1

Patient successfully undergone early PCI, showed

stenosis 90% at osteal to proximal LAD and stenosis 70%
at proximal RCA
CASE 2
 CASE 2

• Male, 62 y.o came with chief complain SOB (+) since 2

hours PTA. Patient can’t lay down and prefer to be in
sitting position. Before that, he felt chest pain since 6
hours ago. Chest pain felt like heavy sensation
accompanied by cold sweat and nausea.
• Patient had a history of hypertension, DM and
dyslipidemia, but not taking his medicine regularly.
Smoking (+)
• While we record the ECG, patient suddenly look sleepy
and difficult to answer question. BP: 82/68 mmHg, HR :
125 x/mnt, RR: 28 x/mnt, Sat O2: 89% on FM 10 lpm,
distended JVP, diffuse bilateral rales on both lung, cold
and clammy extremity.
What is your initial assessment?

A. Anterior STEMI Killip I

B. Anteroseptal STEMI Killip III
C. Extensive anterior STEMI Killip III
D. Extensive anterior STEMI Killip IV
E. Inferior STEMI Killip IV
What is your initial management?
A. Loading fluid 4 cc/kg until MAP >65 mmHg or sign of
fluid overload appears
B. Administer dobutamine 5 mcg/kg/min uptitrated
C. Start furosemide drip 5 mg/hour to relieve congestion
D. Adding ISDN drip 2 mg/hour to relieve chest pain
E. All of the above
Do you think this patient require invasive
ventilatory support?
A. Yes, because patient saturation goes below normal limit with maximal
non-invasive ventilation
B. No, because with non-invasive ventilation patient did not experience
hypoxemia, hypercapnia and asidocis
What other medication you need to
administer?
A. Acetosal 160 mg (chewed), unfractionated heparin 5000 IU
cont’ with 12 IU/kg/hours for 24 – 48 hours
B. Acetosal 160 mg (chewed), clopidogrel 600 mg, unfractionated
heparin, 5000 IU cont’ with 12 IU/kg/hours for 24 – 48 hours
C. Acetosal 160 mg (chewed), clopidogrel 600 mg, enoxaparin 0.6
ml IV, nitroglycerin drip IV
D. Acetosal 160 mg (chewed), clopidogrel 600 mg, enoxaparin 0.6
ml, bisoprolol 5 mg
E. Acetosal 160 mg (chewed), clopidogrel 600 mg, enoxaparin 0.6
ml, bisoprolol 5 mg, ISDN 5 mg sublingual
 Unfractionated heparin is a commonly used anticoagulant in MI and CS, Low-
molecular-weight heparin and fondaparinux in the post-PCI setting may be less
ideal because of the high prevalence of acute kidney injury in CS.
What is your planning for this
patient?
a. Patient had STEMI with sign of shock, proceed to catheterization laboratory for PCI
b. Prepare for fibrinolytic therapy if patient had no contraindication
c. Do a serial ECG to evaluate whether it will have an evolution into ST elevation
d. Conservative strategy and stabilize and monitor the patient in ICCU
CASE 3
 CASE 3

• Male, 46 year old, came with chief complained epigastric pain

since 10 hours PTA, felt like burning sensation. No radiation but
profuse cold sweat. The patient slightly feel nauseous but no
vomiting. Patient tried to relieve the pain with antacid, since the
patient thought it was sort of indigestion, but the pain still getting
worse. History of hypertension (+), smoking (+) dyslipidemia
 Patient fully alert, BP: 141/101 mmHg, HR : 108 x/mnt, other
examination within normal limit
What will you do next?

A. Send the patient home and follow-up his condition in outpatient

clinic
B. Take 12-lead ECG recording to evaluate ischemic changes
C. Take initial and 6-hour cardiac biomarker
D. Proceed to the treadmill stress test
E. B and C
 What is your
interpretation?
It is his cardiac
marker value.
What is your
diagnosis?

A. UAP
B. NSTEMI
C. Non-cardiac
chest pain
Immediate care of this patient includes…
a.Loading Dual Antiplatelet
b.Loading Dual Antiplatelet + Anticoagulant
c.Loading Aspirin + Anticoagulant + Anti
ischemia
d.Loading Dual Antiplatelet + Anticoagulant
+ Anti ischemia
e.Loading Dual Antiplatelet + Anticoagulant
+ Anti ischemia + Diuretic
Patient is already painf-ree with the
medication. What would you do to
determine the next planning?
A. Stratify the patient risk using GRACE
B. Treadmill stress test
C. Serial ECG
D. Echocardiography
Patient GRACE score is 73. What would
you do next?
A. Conservative therapy, monitor patient in intermediate ward
B. TST before discharged after 2-days of pain-free
C. Early coronary angiography
D. CABG
E. A and B
CASE 4
 CASE 4

 Male 37 y.o came with chief complain chest pain

since 3.5 hours PTA. Chest pain felt like heavy
sensation, accompanied by nausea and vomiting.
Syncope (+) just after the chest pain began. SOB (+)
and felt better in sitting position. Smokes 5
packs/day since he was young. His father had heart
disease.
 Patient fully alert, BP: 115/65 mmHg, HR: 82x/mnt,
slightly distended JVP, bilateral rales on one-third
lower lung, other examination within normal limit
CASE 3
 CASE 4
What is your diagnosis?
A. Anterior STEMI Killip II
B. Anterolateral STEMI Killip I
C. Anterior extensive STEMI Killip II
D. Inferolateral STEMI Killip II
E. UAP dd/ NSTEMI
 CASE 3
Calculate his TIMI score!
A. 3
B. 4
C. 5
D. 6
E. 7
 CASE 4
What is your initial management?
A. Loading acetosal 160 mg, clopidogrel 600 mg, enoxaparin 0.3
cc IV followed by subcutaneous dose, ISDN 5 mg SL, furosemide
60 mg bolus IV and and proceed to the primary PCI
B. Loading acetosal 160 mg, clopidogrel 300 mg, enoxaparin 0.3
cc IV followed by subcutaneous dose, ISDN 5 mg SL and
proceed to the primary PCI
C. Loading acetosal 160 mg, clopidogrel 300 mg, enoxaparin 0.3
cc IV followed by subcutaneous dose, ISDN 5 mg SL and
proceed to the fibrinolytic checklist
D. Loading acetosal 80 mg, clopidogrel 160 mg, UFH bolus IV
continued by IV infusion, furosemide 60 mg bolus IV proceed
CASE 4

What can you interpret

from this X-Ray?
 CASE 4
A. Mitral heart configuration with LA dilatation
B. Aortosclerosis heart disease with aortic knob calcification
C. Cardiomegaly with pulmonary edema
D. Fibroinfiltrat in both lung suggesting pneumonia
E. Massive pleural effusion
 CASE 4
Nearest PCI-capable hospital is 3 hours apart. So what is you
next plan?
A. Continue conservative therapy
B. Explain about fibrinolytic therapy
C. Increase the dose of dual antiplatelet and anticoagulan
D. Adding nitroglycerine IV to reduce pulmonary congestion
E. Proceed to CABG
Patient’s family agreed to fibrinolytic therapy. After fibrinolytic, there was no resolution
of ST segment and chest pain did not relieved. What is your conclusion?
A. Successful fibrinolytic, refer to the nearest PCI-capable hospital in 2 – 24 hours
B. Failed fibrinolytic, continue with conservative therapy
C. Failed fibrinolytic refer to the nearest PCI-capable hospital to do rescue PCI
CASE 5
 CASE 5

 Male, 45-year-old came with chief complain chest pain since

yesterday night (18 hours PTA). Felt like heavy sensation radiated to
the back and left arm, accompanied by diaphoresis, nausea and
vomiting
 Patient first seek medical attention to private hospital next town and
was advised to go to your hospital for further medical management.
From the previous hospital, patient was given ISDN drip 2 mg IV,
asetosal 160 mg and clopidogrel 300 mg. Patient said that the pain
did not relieved after taking the medication.
 Patient has DM for 12 years, but with no good adherence to the
medication.
 Fully alert, BP: 117/86 mmHg, HR: 108x/mnt, other examination within
normal limit
 CASE 5
What is your initial diagnosis?
A. Inferior STEMI late onset
B. Anterolateral STEMI late onset
C. Posterior STEMI late onset
D. Anterolateral ischemia, probably UAP or NSTEMI
E. Dyspepsia
What is your next planning for the patient?
A. Revascularization therapy despite the late onset (>12 hours)
B. Conservative strategy since it is late onset and no evidence on on-
going ischemia
 CASE 4

What is your next planning?

A. Proceed to revascularization therapy although it is
late onset (>12 hours)
B. Proceed to conservative therapy since it is late
onset
 CASE 5

Patient agreed to do early PCI. What other

medication you need to administer?
A. Adding clopidogrel 300 mg
B. Atorvastatin 40 mg
C. Bisoprolol 1.25 mg
D. Enoxaparin bolus 0.5mg/kgBB IV dianjutkan
dengan enoxaparin 0.1 mg/kgBB SC
E. All of the above
CASE 5
 CASE 5
A 61 year old male came to the ER complaining of
substernal chest pain while shoveling 2 hours PTA.
He rates the pain as 8 on a scale of 1 - 10. He is
slightly diaphoretic. His BP is 154/88. His pulse rate is
102. His pulse oximetry is 98% on room air. He had
no past medical history.
 CASE 5
You quickly obtain IV access and complete a 12
Lead ECG which is shown below. Your diagnosis is…
 CASE 5
What is your conclusion from the ECG
above?
A. Lateral wall infarction
B. Normal ECG – his pain is not cardiac
C.Anterior wall infarction
D. Inferior wall infarction
Locating infarction
 CASE 5
The ST depression noted in Leads V1, V2 and V3
most likely represents…
A. An anterior wall infarction
B. A secondary infarction
C. A normal finding on an ECG
D. Reciprocal changes
 CASE 5
What is your next step?
a.Concluded that it is STEMI inferior
b.Concluded that it is NTEMI anterior
c.Repeat the ECG with posterior recording
d.Repeat the ECG with posterior and right-side
recording
e.We cannot make a conclusion yet. Check serial
ECG to see the evolution and order cardiac
marker testing
Posterior

Right-side
 CASE 5
What is your diagnosis?

a.STEMI Anterior
b.STEMI Inferior
c.STEMI Inferoposterior
d.STEMI Inferoposterior + RV infarct
e.STEMI Inferior + RV infarct
 CASE 5
This patient most likely has experienced…

A. Occlusion of the right coronary artery

B. Occlusion of a carotid artery
C. Occlusion of the left anterior descending
artery
D. Occlusion of a left main artery
 CASE 5
Immediate care of this patient includes….

A. Oxygen administration, aspirin and rtPA

B. Lipitor, nitroglycerin and aspirin, rtPA
C. Oxygen, emergency catheterization, and
vasopressor
D. Fluid therapy, DAPT, anti-ischemia,
anticoagulant and emergent
catheterization
 CASE 5
The nearest hospital with capability to undergo PCI is
4 hours apart. What will you do next?

A.Choose conservative therapies and administer oral

therapies
B.Transfer the patient to that hospital for primary PCI
is still indicated in this patient
C.Prepare the patient to fibrinolytic therapy if there
isn’t any contraindication
THANK YOU