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case presentation Done by :AHDAB KHAYAT

case presentation Done by :AHDAB KHAYAT. Myocardial infarction. Cellular death or necrosis of cardiac muscle and surrounding tissue secondary to severe or prolonged ischemia. Epidemiology. 1.5 million Americans have an AMI each year

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case presentation Done by :AHDAB KHAYAT

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  1. case presentation Done by :AHDAB KHAYAT

  2. Myocardial infarction • Cellular death or necrosis of cardiac muscle and surrounding tissue secondary to severe or prolonged ischemia.

  3. Epidemiology • 1.5 million Americans have an AMI each year • Mortality ranges from 10 to 15 % during the first year , decrease to 3.5 % per year

  4. Pathophysiology • Atherosclerosis • thrombosis • Myocardial necrosis

  5. Etiology • Coronary thrombosis due to ruptured plaque including platelet aggregation • Coronary artery spasm • Embolic infarction • Cocaine induced vasospasm

  6. Clinical presentation Acute chest pain or discomfort Radiated to an upper extremity Associated with diaphoresis , nausea and vomiting

  7. Chest pain • Gradual in onset • Provoked by an activity • Not change by position or respiration • Difficult to localize • Last longer than 30 min

  8. Risk factor • Family history of CHD • age • sex • DM • hypertension • hyperlipidemia • cigarette smoking • cocaine use

  9. Diagnosis • ECG • Cardiac enzyme monitoring -CK MB : 3-6hr, peak12-24hr normal 36-48hr -LDH : 24-48hr, peak 3-6d -Troponins : late marker

  10. complication • CHF • Cardiogenic shock • Myocardial rupture • Dysrhythmia • Deep venous thrombosis • Pulmonary embolism

  11. Goals of therapy • Limit extension of myocardial necrosis • Prevent reinfarction • Control complications -pain -hyper or hypotension -CHF -ventricular irritability

  12. Nonpharmacologic therapy • Bed rest during first 24hr after acute eventdecrease myocardial O2 consumption prevent extension of infarction during healing • Start low saturated fat and cholesterol diet • Stop smoking

  13. Treatment plan • O2 2-4 L/min Is administered unless the patient has sever chronic obstructive pulmonary disease • ASA antiplatelet effect 325 mg po then 162mg po or plavix 75 mg po (ASA allergy) or ASA 325 mg then 81-162 mg OD + plavix 300 mg then 75mg po OD

  14. Nitrates to relieve ischemic pain Nitroglycerin infusion 10mcg/min syst>90 or SL 0.4 mg q5min up to 3 tab or spray 0.4 mg/aerosol q5min BID

  15. Heparin as adjunctive therapy to prevent rethrombosis 60U/kg IV push then 15U/kg/hr IV infusion (monitor APTT ) • Glycoprotein IIb/IIIa blocker in high risk patient Eptifibatide 180mcg/kg IVP then 2mcg/kg/min for 48-72hr

  16. B blocker slow the heart -atenolol 5mg Iv then 50-100mg po -esmolol 500mcg/kg Iv over min then 50mcg/kg/min Iv infusion ..HR>60

  17. ACEI prevent a build up of fluid by interfering with the enzyme 'angiotensin' which is involved in regulating body fluid lisinopril 2.5-5 mg increase to 10-20mg benzapril 10mg

  18. Long acting nitrate - nitroglycerin patch -isosorbide dinitrate 10-60mg po TID Or isosorbid mononitrate 30-60 mg

  19. Statin -atorvastatin 10mg q HS -simvastatin 40 mg q HS

  20. Symptomatic -morphine 2-4mg Iv prn chest pain -acetamenophin 325-650mg q4-6hr prn headache -lorazepam 1-2 mg TIDprn anxiety -zolpidem 5-10 mg qhs prn insomnia -docusate 100mg BID -famotidine 20mg Iv BID

  21. Cardiac catheterization • An early invasive approach in patient at intermediate to high risk and those in whom conservative management has failed

  22. The patient’s case J.Z 50Y Dr. Nabil AL Ama

  23. J . Z is a 50 years old male admitted at 30/9 under Dr Nabil Al Ama diagnosed with MI • He is married , non smoker • No family history of IHD

  24. PMH : history… DM , HTN , unstable angina dyslipidemia 3 days back discharge..unstable angina plavix, ASA, capotin, atenolol, isordil neurobion, amlor, amaryl, lactulose zocor.

  25. CASE ER 30/9/2006 CC : sever chest pain

  26. Treatment plan

  27. Lap result

  28. Drug interaction • Hypoglycemic effect enhanced by ACEI • Hypoglycemic effect enhanced by NSAIDs • B blocker mask sign of hypoglycemia • ACEI,B blocker,Ca blocker and nitrate enhance hypotensive effect • Plavix enhance bleeding risk with ASA and heparin

  29. recommendation • Close monitoring of BP and glucose level • Start diabetic diet • Replace oral hypoglycemic by insulin  glucose level not controlled • Decrease dose of pantoprazole to 20mg/d ( prophylaxis of NSAIDs ) • Replace lactulose by bisacodyl 5-10mg at night or docusate 100mg BID….DM • WT reduction for cardiac catheterization

  30. References • Christopher T, Alexander M, Sukhdev C: The hand-on guide to clinical pharmacology. 2nd ed.USA: Blackwell; 2005 • Parveen K, Michael C: Clinical medicine.5th ed.UK: W.B.Saunders; 2002:701-832 • Seymour K, Eli DE: Clinician’s handbook of prescription drugs. International ed.USA:Mc-Graw-Hill;2001 • Paul D Chan MD , Christopher R Winkle MD current clinical strategies , Family medicine 2006 edition • Paul D Chan MD Margaret T Johnson MD treatment guidelines for medicine and primary care 2006 edition

  31. Thanks for your attention

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