Case on ACS – Inferior wall Myocardial Infarction

By: Abhimanyu Parashar 5th Pharm.D

ACS

Myocardial infarction0 Myocardial infarction (MI) or acute myocardial

infarction (AMI), commonly known as a heart attack

0 Typical symptoms of acute myocardial infarction:1. Chest pain (typically radiating to the left arm or left side of the

neck) 2. shortness of breath3. Nausea4. Vomiting5. Palpitations6. Sweating7. Anxiety8. Fatigue

Classification0 There are two basic types of acute myocardial

infarction based on pathology:1. Transmural:0 Anterior0 Posterior0 Inferior0 lateral 0 Septal2. Subendocardial: 0 Involving a small area in the subendocardial wall of

the left ventricle, ventricular septum, or papillary muscles

0 A 2007 consensus document classifies myocardial infarction into five main types

1. Type 1 – Spontaneous myocardial infarction2. Type 2 – Myocardial infarction secondary to

ischemia3. Type 3 – Sudden unexpected cardiac death,

including cardiac arrest4. Type 4 – Associated with coronary angioplasty or

stents5. Type 5 – Myocardial infarction associated

with CABG

0 Age : 63 years

0 IP No. 1289064

0 Unit : Vikram Hospital (Dept. Cardiology)

Reasons for admission

C/O:

0 Acute onset of Retro-sternal burning sensation 0 Mild sweating0 Giddiness

Patients History

0 PMHx: K/C/O Type 2 DM with Hypertension since 5 years

on Tab. Amace ( Amlodipine+ Enalpril) 1-0-0 Tab. Ecosprin (Aspirin 150 mg) 0-1-0 Tab. Dibizide M (Glipizide + Metformin)1-0-0 Tab. Melmet 500 (Metformin) mg 0-0-1

0 SHx: Smoker since 1 year Alcoholic

General examination

0 BP : 120/80 mmHg Pulse : 80 BPM

0 CVS: S1S2 +0 ECG: Inferior Wall MI0 Impression : ACS- IW.MI with T2DM and HTN

0 ADV : 2-D ECHO, Troponin-I, CKMB, CPK, RBG, Hb, HCT, TC, S.Cr, Electrolytes, TSH.

DAY 1

0 BP : 120/80 mmHg Pulse : 80 BPM0 CVS :S1S2 +0 2D ECHO: IHD, Hypo-kinetic basal Inferio-Posterior

wall Ejection fraction: 50 % Troponin I: +ve Impression: ACS0 At 9 PM : GC stable , No Angina/ Dyspnea Vitals : Normal0 ADV: CST

CBG (BB): 177 mg/dlCBG (BL): 231 mg/dlCBG (BD): 102 mg/dl

Lab ReportsBiochemistry

CPK 170 (55-170 U/L)

CKMB 6.25 (0-3.38 ng/ml)

TROP-I 0.086 (0-0.035 ng/ml)

Glucose (R) 245 mg/dl

Urea 21 mg/dl

S.Cr 0.80 mg/dl

electrolytes

Sodium 132 mg/dl

Potassium 4.6 mg/dl

TSH 3.49 (0.465-4.68 micro IU/ml)

Hematology

Hb. 15

HCT 41.9 % (42 to 52 %)

MCV 87.7 fl (80 to 96 fl )

MCH 31.4 (27-33 pg /cell )

RBC 4.78 Lakhs Cell/cumm

PLT 2.36 Lakhs cell/cumm

WBC 12160 cell/cumm

Polymorphs 75.8 %

L 18

M 55

E 05

B 01

Treatment chart

Drugs Dose R F

Inj. Heparin 5000 U IV Q8H

T. Aspirin 150 mg PO 0-1-0

T. Clopidogrel 75 mg PO 1-0-1

T. Trimetazidine MR 35 mg PO 1-0-1

T. Atorvastatin 40 mg PO 0-0-1

Syp. Cremalax (Na. Picosulfate) PO 0-0-1

T. Pantoprazole 40 mg PO 1-0-0

T. Restyl ( Alprazolam) 0.5 mg PO 0-0-1

T. Amace (Amlodipine + enalpril) 5+5 mg PO 1-0-0

Inj. Actrapid if sliding scale > 200 mg/dl

T. Isosorbide Dinitrate 2.6 mg SL 1-1-0

DAY 2

0 BP : 130/80 mmHg Pulse: 88 BPM 0 CVS: S1S2 + , SSM + RS: Clear0 ADV: CST, CAG counseling

At 5 PM: GC fair , No Angina/ Dyspnea0 Troponin I: +ve 0 ADV: CST and CAG after RFT

RBG : 231 mg/dl CBG (BB): 172 mg/dlCBG (BL): 148 mg/dlCBG (BD): 245 mg/dl

04/11/2023 17

Thrombolysis in Myocardial Infarction

Treatment chartDRUGS Dose R F

Inj. Heparin 5000 U IV Q8H

T. Aspirin 150 mg PO 0-1-0

T. Clopidogrel 75 mg PO 1-0-1

T. Trimetazidine MR 35 mg PO 1-0-1

T. Atorvastatin 40 mg PO 0-0-1

Syp. Cremalax PO 0-0-1

T. Pantoprazole 40 mg PO 1-0-0

T. Restyl (Na. Picosulfate) 0.5 mg PO 0-0-1

T. Amace (Amlodipine + enalpril) 5+5 mg PO 1-0-0

T. Dibizide M (Glipizide + Metformin) 5+500 mg PO 1-0-0

T. Melmet (Metformin) 500 mg PO 0-1-1

T. Isosorbide Dinitrate 2.6 mg SL 1-1-0

Inj. Actrapid if sliding scale > 200 mg/dl

DAY 3

0 BP : 120/80mmHg Pulse : 72 BPM0 CVS : S1S2 + RS: NVBS +0 RBS: 172 mg/dl CBG (BB) : 180 mg/dl0 ADV: CAG and CST0 CAG report: Triple vessel disease PTCA + stent of OM + LCX0 Post CAG: TVD, No Angina/ Dyspnea Vitals: Normal0 ADV : CST , Counseling for PTCA + stent of OM and

CLX

Coronary Angiography Reports

Coronary Angiography Reports

Treatment chartDRUGS Dose R F

Inj. Heparin 5000 U IV Q8H

T. Aspirin 150 mg PO 0-1-0

T. Clopidogrel 75 mg PO 1-0-1

T. Trimetazidine MR 35 mg PO 1-0-1

T. Atorvastatin 40 mg PO 0-0-1

Syp. Cremalax (Na. Picosulfate) PO 0-0-1

T. Pantoprazole 40 mg PO 1-0-0

T. Restyl (Alprazolam) 0.5 mg PO 0-0-1

T. Amace (Amlodipine + Enalpril) 5=5 mg PO 1-0-0

T. Dibizide M (Glipizide + Metformin) 5+ 500 mg PO 1-0-0

T. Melmet (Metformin) 500 mg PO 0-1-1

T. Isosorbide Dinitrate 2.6 mg SL 1-1-0

Inj. Actrapid if sliding scale > 200 mg/dl

DAY 4

0 BP : 120/80 mmHg Pulse : 80 BPM0 CVS : S1S2 +0 Post CAG – TVD 0 NO Angina/ Dyspnea0 ADV: CST , Discharge

Treatment chartDRUGS Dose R F

Inj. Heparin 5000 U IV Q8H

T. Aspirin 150 mg PO 0-1-0

T. Clopidogrel 75 mg PO 1-0-1

T. Trimetazidine MR 35 mg PO 1-0-1

T. Atorvastatin 40 mg PO 0-0-1

Syp. Cremalax (Na. Picosulfate) PO 0-0-1

T. Pantoprazole 40 mg PO 1-0-0

T. Restyl (Alprazolam) 0.5 mg PO 0-0-1

T. Amace (Amlodipine+Enalpril) 5+5 mg PO 1-0-0

T. Dibizide M (Glipizide + Metformin) 5+ 500 mg PO 1-0-0

T. Melmet (Metformin) 500 mg PO 0-1-1

T. Isosorbide Dinitrate 2.6 mg SL 1-1-0

Inj. Actrapid if sliding scale > 200 mg/dl

DRUG DOSE R F 1 2 3 4

Inj. Heparin 5000 U IV Q8H + + + _

T. Aspirin 150 mg PO 0-1-0 + + + +

T. Clopidogrel 75 mg PO 1-0-1 + + + +

T. Trimetazidine MR 35 mg PO 1-0-1 + + + +

T. Atorvastatin 40 mg PO 0-0-1 + + + +

T. Cremalax (Na. Picosulfate) PO 0-0-1 + + + +

T. Pantoprazole 40 mg PO 1-0-0 + + + +

T. Restyl (Alprazolam) 0.5 mg PO 0-0-1 + + + +

T. Amace (Amlodipine+Enalpril) 5 + 5 mg PO 1-0-0 + + + +

T. Dibizide M (Glipizide + Metformin)

5+ 500mg PO 1-0-0 _ + + +

T. Melmet 500 mg PO 0-1-1 _ + + +

T. Isosorbide Dinitrate 2.6 mg SL 1-1-0 + + + +

Inj. Actrapid if sliding scale > 200 mg/dl

SC

Discharge MedicationDRUG DOSE R F COST/TAB COST/DAY

T. Aspirin 150 mg PO 0-1-0 0.80 Rs 0.80 Rs

T. Clopidogrel 75 mg PO 1-0-1 6.2 Rs 12.40 Rs

T. Trimetazidine MR 35 mg PO 1-0-1 7.5 Rs 15 Rs

T. Atorvastatin 40 mg PO 0-0-1 20 Rs 20 Rs

T. Amlopdipine+Enalpril 5+5 mg PO 1-0-0 4 Rs 8 Rs

T. Glipiizide +Metformin 5+500 mg PO 1-0-0 0.75 Rs 0.75 Rs

T. Metformin 500 mg PO 0-1-1 1.5 Rs 3 Rs

T. Pantoprazole 40 mg PO 0-0-1 6 Rs 6 Rs

T. Isosorbide Dinitrate 2.6 mg SL SOS __

Total : 66 Rs/Day

PHARMACEUTICAL CARE PLAN

0 SUBJECTIVE EVIDENCE:

1. Retro-sternal burning sensation

2. Mild sweating3. Giddiness

0 OBJECTIVE EVIDENCE:

1. ECG: Inferior Wall MI2. 2D ECHO: IHD, Hypo-

kinetic basal Inferio-Posterior wall

3. Troponin I: +ve (0.086 ng/ml)

4. CKMB: (6.25 ng/ml)5. CAG report: Triple vessel

disease

Final Diagnosis

ACS- Inferior wall MI with Triple Vessel Diseases with Hypertension and Type

2 Diabetes Mellitus

Goals of Treatment0 Short term goals :1. Initial evaluation & stabilization2. Relief of ischemic chest discomfort3. Efficient risk stratification4. Focused cardiac care5. Early restoration of blood flow to the infarct-related

artery to prevent infarct expansion.6. Increase myocardial oxygen delivery7. Prevention of death and other complications

0 Long term goals:1. Prevent complications and recurrences. 2. Reduce mortality and improve quality of life

Treatment OptionsFor Hypertension For

IHDFor T2DM

• ACE- inhibitors – Enalpril

• ARB’s – Telmisartan

• CCB’s- Dihydropyridine

Amlodipine

• Diuretics – Furosemide• Beta Blockers – Atenolol Metoprolol

• Anti-Platelet agents – Aspirin , clopidigrel

• Anti-anginal – Trimetazidine Nicorandil Ranolazine

• Anti- Hyperlipedimic agents –

Atrovastatin

• Vasodilators- Nitrates

•Sulfonylureas – Glipizide

•Biguanides – Metformin

•Insulin

0 Signs and symptoms were reduced by day 2

0 Lipid profile not done

GOALS ACHIEVED Problems Identified

Monitoring Parameters

0 Disease related :1. Blood Pressure2. ECG3. 2D-ECHO4. Blood Glucose levels5. Hb A1c6. Lipid Profile

0 Drug related :1. Platelets count2. Blood pressure

Patient Counseling

About Disease

About PTCA0 Advantages:1. It can be done under local anesthesia. 2. The procedure is faster. Recovery period is shorter

and less painful3. The procedure does not leave a noticeable scar4. It is a useful procedure for patients unwilling or

unable to undergo surgery.5. A repeat procedure, if required, is easier to perform

than a repeat bypass surgery.

0 Disadvantages:1. Coronary angioplasty can be used only if one or two

arteries are affected2. It cannot be used in arteries that cannot be reached

by the catheter3. It may not be effective against very hard

atherosclerotic plaques.4. Restenosis may occur, especially if a stent is not

placed during the procedure

About Medications0 Name and purpose

0 Dose and frequency

0 Medication adherence

0 Possible adverse effects

0 Missed dose

About life style modification

0 Healthy life style with daily exercise (the ADA recommends 150 min/week (distributed over at

least 3 days) of aerobic physical activity)0 Self-Monitoring of Blood Glucose 0 Nutritional recommendations0 Driving: no driving for 1month. after Ml. 0 Flying: most airlines will not carry passengers for 2wk.

post Ml and then only if able to climb 1 flight of stairs without difficulty

0 Physical activity: advise gradual increase in activity

1. 2wk. after Ml stroll in garden or street2. 4wk. after Ml walk @ ½ mile/d.3. 4 to 6wk. after Ml increase to 2 miles/d. by 6wk.4. From 6wk increase the speed of walking; aim 2 miles in <30min.

0 Sexual activity: resume after 6wk

0 Return to work : 1. Sedentary workers 4-6wk. after uncomplicated Ml2. Light manual workers 6-8wk. after uncomplicated Ml3. Heavy manual workers 3months after uncomplicated Ml

0 Monitoring health: continue regular reviews at least annually for lifelong. Check for symptoms and signs of cardiac dysfunction (breathlessness, palpitations, angina).

0 Secondary prevention0 Smoking cessation0 Hypertension ,Check BP and refer physician if >140/900 Alcohol withdrawl.

Fat 20–35% of total caloric intakeSaturated fat < 7% of total calories<200 mg/day of dietary cholesterolTwo or more servings of fish/week provide -3 polyunsaturated fatty acids

Carbohydrate 45–65% of total caloric intake (low-carbohydrate diets are not recommended)Sucrose-containing foods may be consumed with adjustments in insulin dose

Protein 10–35% of total caloric intake (high-protein diets are not recommended)

Other components Fiber-containing foods may reduce postprandial glucose excursions

Nonnutrient sweeteners

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