Section 3F-1

CTN A: Case 1

A. Problem List

MYOCARDIAL INFARCTION

Sustained chest pain described as crushing

and like an elephant in my chest
Radiates to the left arm and jaw
10/10 intensity
Diaphoretic

S3, S4 heart sounds

BP: 180/110
HR: 105bpm
Pain is
o
ECG: 3mm ST elevation
Q wave leads 1 & V2 V4
CK-MB: 12% (NV: 0-5%)
Trop-I: 60ng/mL (NV: <2)
Inferior infarct

DIABETES MELLITUS

Glucose: 149mg/dL (NV: 80-120mg/dL)

Hb1Ac: 6.8% (<6.5 %)

HYPERTENSION

BP: 180/110 upon admission (usual BP of

patient: 140/85)

HYPERCHOLESTEROLEMIA

Cholesterol Level: 259 mg/dL (NV: 150200mg/dL)

HYPERTRIGLYCERIDEMIA

Triglycerides: 300 mg/dL (NV: <150 mg/dL)

CORONARY
DISEASE

Middle LAD Coronary Artery (75% stenosis)

Proximal LCX Coronary Artery (30% stenosis)

ARTERY

B. Therapeutic Options

CLASSIFICATION OF MI: type 4B- Myocardial Infarction Related to Stent Thrombosis

REPERFUSION THERAPY FLOWCHART

THERAPEUTIC OPTIONS
Myocardial Infarction
MAIN
Fibrinolytic Therapy:
Altepase (tPA)
- Recombinant human t-PA
- directly or indirectly aid conversion of
plasminogen to plasmin, which
cleaves thrombin and fibrin clots.
- Preferentially activate plasminogen
that is bound to fibrin, which (in
theory) confines fibrinolysis to the
formed
thrombus
and
avoids
systemic activation.

ALTERNATIVE

Side effects: bleeding

Contraindication:
active bleeding,
recent surgery
severe hypertension.
BP should be stabilized before.
Morphine Sulfate
- is an effective analgesic for the patients
discomfort.
- The patients body is in severe stress;
thus increased workload for the patients
heart.

Meperidine:
- Strong u receptor agonist
- variable affinity for D and K
receptors with anti cholinergic effects
- 50-75 mg oral or IV

By relieving the pain, stress levels will go

down, the workload will decrease as well
as oxygen demand.
Dosage: 15/30 mg oral for 4 hours

Oxygen
- 2-4 L/minute by nasal cannula for the
first 6-12 hours
- Can be administered if patient is
hypoxemic.
- 5 mcg 20 mcg every 3-5 minutes
Anticoagulant.
Unfractioned heparin
- Activates antithrombin, which decreases
the actin of IIa (thrombin) and factor Xa.
PTT should be monitored.
- Dosage: IV 60 u/kg- bolus

Urokinase
MOA: rapidly lyse thrombi by
catalyzing the formation of the serine
protease plasmin from its precursor
zymogen, plasminogen
IV route
prepared from cultures of human
embryonic kidneys
human enzyme that directly converts
plasminogen to plasmin
Plasmin itself cannot be used
because
naturally
occurring
inhibitors in plasma prevent its
effects
TOXICITY:
bleeding
and
hypotension

Antiplatelet:
Aspirin
- irreversibly inhibits COX-1 and COX2 enzyme by acetylation, it also
reduces thromboxane Ar.
- It is used to prevent platelet
aggregation. Common side effects
include gastric ulceration, tinnitus,
upper GI bleeding and interstitial
nephritis.
Dosage: 81-325 mg/day- long term therapy

Heparin
Antithrombin inhibits clotting factor
protease especially thrombin (IIa),
IXa and Xa
Close monitoring of the activated
partial thromboplastin time (aPTT or
PTT) is necessary
Toixicity: bleeding and allergy
Ticlopidine and Clopidogrel
plt aggregation by irreversibly
inhibiting the ADP receptors on
platelets
No effect on platelet metabolism
Effective in patients with TIA
(Transient
Schemic
Attack),
completed strokes and unstable
angina pectoris
Clopidogrel - approved for patients with
Unstable angina or non-ST- elevation

acute myocardial infarction (NSTEMI) in

combination with aspirin; ST-elevation
myocardial infarction (STEMI); Recent
myocardial infarction
Loading dose: 300-600 mg, then
75 mg OD
AE: leukopenia

Primary
Percutaneous
Coronary
Intervention:
- PCI, usually angioplasty and/or stenting
with- out preceding fibrinolysis, referred
to as primary PCI
- effective in restoring perfusion in STEMI
when carried out on an emergency
basis in the first few hours of MI.
- Cardiogenic shock is present, bleeding
risk is increased, or symptoms have
been present for at least 23 h when
the clot is more mature and less easily
lysed by fibrinolytic drugs.
MANAGEMENT
DIABETES MELLITUS
Glargine
- long acting insulin
- reduces the risk of nocturnal
hypoglycemia in a diabetic
patient
- can be combined with Metformin
to better maintain glucose levels
throughout the day.
- Dosage:
Metformin
- biguanide
- lowers blood glucose by suppressing
hepatic production of glucose and
the metabolism of glycogen in the
liver.
- Decreases glucose absorption in the
gastrointestinal tract increase fatty
acid
oxidation
and
enhances
peripheral glucose uptake of skeletal
muscle
by
increasing
insulin
sensitivity.
- Contraindication: renal insufficiency

Risk in developing lactic acidosis.

Suitable for use in patient s with
heart failure but monitoring renal
function is necessary.
Should be stopped when there is
significant reduction in GFR.

HYPERLIPIDEMIA
Atorvastatin
Bile Acid Binding Resins (BABR)
- Statin
Cholestyramine,
Colestipol,
- Lowers cholesterol and triglycerides
Colessevelam
by competitively inhibiting the
MOA: sequestration of bile acids in
enzyme HMG-CoA reductase.
the intestine, prevent reabsorption
- The
impaired
synthesis
of
enterohepatic circulation, decrease
cholesterol in the liver lowers the
absorption of exogenous cholesterol,
levels of cholesterol in the blood
increase metabolism of endogenous
reducing the risk of atherosclerotic
cholesterol via 7-hydroxylation
formation and stabilizing existing
OTHER EFFECTS: improve glucose
atherosclerotic lesions.
metabolism (GLT-1 (glucose like
- Has fluorine substituent and is given
peptide that promotes insulin
in active form.
secretion glucose uptake glucose
- A long acting agent
levels), reduce CHD events
- Contraindication: liver problems
- Liver function must be done before
starting and during treatment.
- Weakness and muscle pain should
be monitored as there can be
serious muscle side effects.
HYPERTENSION
Nitroglycerine
- Vasodilate by increasing nitric oxide in
vascular smooth muscle, leading to
increase in cGMP and smooth muscle
relaxation.
- Will decrease myocardial oxygen
demand by lowering preload and
increase myocardial oxygen supply by
dilating infarct-related coronary vessels
or collateral vessels.
- Chest pain was not relived after a total of
eight
sublingual
nitroglycerin.
Nitroglycerin is a fast acting medication.
If SL NTG is not working, administering
NTG through continuous IV infusion will
be effective.

Thiazide Diuretics
Hydrochlorothiazide These drugs work
by reducing reabsorption of salt and water in
the renal tubules, causing larger amounts
of water to be excreted in the urine. Like
calcium channel blockers.
Based on the mechanism of action of these
drugs, they are relatively safe for the
patient.

C. Supportive Treatment
Nutritional Support
Because of the risk of emesis and aspiration soon after STEMI, patients should
receive either nothing or only clear liquids by mouth for the first 412 h. The typical
coronary care unit diet should provide 30% of total calories as fat and have a
cholesterol content of 300 mg/d. Upon stabilization, avoid red meat, shortening,
margarine and commercially processed foods. Red meats contain saturated fats.
Shortening, margarine and commercially processed foods are rich in trans-fatty acids.
Saturated fats and trans-fatty acids are found to be the major cause of heart disease.
The patient can get protein from fish or from vegetable products such as soy. Fish
contains unsaturated omega-3 fatty acids that reduce blood cholesterol. Complex
carbohydrates should make up 5055% of total calories. Portions should not be
unusually large, and the menu should be enriched with foods that are high in potassium,
magnesium, and fiber, but low in sodium. Eat plenty of magnesium rich foods such as
tofu, wheat germ, broccoli, potatoes, spinach and chard to help regulate heart activity.
Garlic lowers cholesterol and triglycerides, prevents thrombus formation and lowers
blood pressure. Advise the patient that he can eat three fresh cloves daily and can add it
to his salad. Diabetes mellitus and hypertriglyceridemia are managed by restriction of
concentrated sweets in the diet.
Exercise
Factors that increase the work of the heart during the initial hours of infarction
may increase the size of the infarct. Therefore, patients with STEMI should be kept at
bed rest for the first 612 h. However, in the absence of complications, patients should
be encouraged, under supervision, to resume an upright posture by dangling their feet
over the side of the bed and sitting in a chair within the first 24 h. This practice is
psychologically beneficial and usually results in a reduction in the pulmonary capillary
wedge pressure. In the absence of hypotension and other complications, by the second
or third day, patients typically are ambulating in their room with increasing duration and
frequency, and they may shower or stand at the sink to bathe. By day 3 after infarction,
patients should be increasing their ambulation progressively to a goal of 185 m (600 ft)
at least three times a day.
Herbal or Alternative Medicine
There are some herbal medicines that are useful to help prevent another heart
attacks, and to heal after an attack. Ginkgo biloba increases the blood supply to the
brain, prevents accumulation of blood platelets and controls angina. Take 20 drops of
tincture three times daily. Take two 40 mg capsules of 24% standardized extract. (Note:
If you take prescription blood-thinning medication, consult your health care provider
before using ginkgo.) Ginger has a tonic effect on the heart, lowers cholesterol and
inhibits blood platelet collection. Make a fresh ginger infusion using 2 slices of fresh root
per cup of water. Take 2 cups daily. Green tea has superb antioxidant properties.
Drinking 10 to 20 cups a day can provide protection against heart disease and many

other illnesses. (Note: If you take prescription blood-thinners, consult your doctor before
taking green tea in capsule form. Turmeric can lower blood cholesterol.
D. Follow-up Scheme

The patient should come for a follow-up once a week, until advised otherwise by
the physician to ensure stability of the patients condition. Blood chemistry and ECG
must be done to monitor the condition of the kidneys, monitor cholesterol and lipid levels
and to monitor the condition of the heart. Monitored glucose levels should be monitored
to ensure control of diabetes mellitus.
E. Prevention Plan
Evidence based interventions for secondary prevention include the use of aspirin,
beta-blockers, angiotensin converting enzyme inhibitors; lipid lowering drugs and other
anti- hypertensives, as well as modifying lifestyle related risk behaviours.
Stopping smoking
Apart from these pharmacological measures for secondary prevention,
evidence is available that lifestyle measures such as stopping smoking, encouraging
a healthy diet and exercise can also significantly contribute to reduction in
cardiovascular mortality in people with established CVD. Evidence from
epidemiological studies indicates that people with coronary heart disease who stop
smoking rapidly reduce their risk of recurrent coronary events or death. In the case of
stroke survivors, observational studies have shown that the excess risk of stroke
among former smokers largely disappeared 2-4 years after smoking cessation.
Diet
With regard to diet, patients with MI are advised to eat more fish, fruit and
vegetables, bread, pasta, potatoes, olive oil and margarine may result in a substantial
survival advantage.
Physical exercise
Although the role of exercise alone in reducing cardiovascular outcomes is not
clear, studies have found that cardiac rehabilitation which includes physical exercise
improves coronary risk factors and reduces the risk of major cardiac events in people
after MI.
Myocardial ischemia is caused by a discrepancy between the demand of the
heart muscle for oxygen and the ability of the coronary circulation to meet the
demand. Physical conditioning usually improves the exercise tolerance of patients. A
regular program of isotonic exercise that is within the limits of the individual patients
threshold for the development of angina. Based on the results of an exercise test,
the number of metabolic equivalent tasks (METs) performed at the onset of ischemia
can be estimated and a practical exercise prescription can be formulated to permit
daily activities that with fall below the ischemic threshold.

F.

Patient Education

Patient advice

Eat a heart-healthy diet, including potassium and fiber; and drink a lot of
water.
Limit the amount of sodium/salt (aim for less than 1500 mg per day),
cholesterol, fat and sugar you eat.
Avoid drinking alcoholic beverages.
Reduce stress: Try to avoid things that cause you stress.
Get enough sleep for at least 6 hours a day.
Stay at a healthy body weight.
If stable, exercise lightly regularly.

Family advice
Have the blood sugar and blood pressure monitored regularly.
Assist the patient for strict compliance with the medicines.
Assist patient in activities in daily life.