grand rounds 2
TRANSCRIPT
-
8/3/2019 Grand Rounds 2
1/57
Presentor: John Hommer E. Dy M.D.Moderator: Joy Marchadesch M.D
-
8/3/2019 Grand Rounds 2
2/57
-
8/3/2019 Grand Rounds 2
3/57
To discuss Acute Coronary Syndrome itsetiology, pathogenesis, diagnosis, treatment and
prevention
-
8/3/2019 Grand Rounds 2
4/57
B.R, Female, 66yo
widowed
Roman Catholic Housewife
From Legazpi City
-
8/3/2019 Grand Rounds 2
5/57
Chest Pain
-
8/3/2019 Grand Rounds 2
6/57
admission
1 week
On and off retro sternal sharp chestpain
Easy fatigability
Few
hours
Chest tightness
Diaphoreses
Difficulty of breathing
Vomiting
-
8/3/2019 Grand Rounds 2
7/57
General: No recent weight change, (+) bodyweakness, (-) fever
Skin: No rashes or pruritus
HEENT: No headache, no blurring of vision, nodifficulty of swallowing
Respiratory: No cough
Cardiovascular: no palpitations
Extremities: Bipedal edema
-
8/3/2019 Grand Rounds 2
8/57
HPN unrecalled duration, unrecalled medicationwith poor compliance
Non-DM
No previous Hospitalization No history of any surgical operation
No allergy to food and drugs
-
8/3/2019 Grand Rounds 2
9/57
(+) HPN mother, siblings
(-) DM
(-) Cancer
(-) bronchial asthma (-) heart disease
-
8/3/2019 Grand Rounds 2
10/57
Non - smoker
Non- alcoholic drinker
-
8/3/2019 Grand Rounds 2
11/57
General Survey: Conscious Coherent
Diaphoretic
In cardio-respiratory distress
-
8/3/2019 Grand Rounds 2
12/57
Vital Signs
BP: 70/50 mmHgCR: 52 bpmRR: 25 cpm
Temp: 36oC
Weight: 51kg
Height: 54BMI: 23O2 sat : 97-98%
-
8/3/2019 Grand Rounds 2
13/57
Skin: Afebrile Good skin turgor Cold to touch
HEENT: Pink palpebral conjunctiva anicteric sclerae
no naso-aural discharge, no tonsillo-pharyngeal congestion
-
8/3/2019 Grand Rounds 2
14/57
Neck:
No cervical lymphadenopathies
no mass
(+) neck vein engorgement Chest/Lungs:
Symmetrical chest expansion
(+) retractions subcostal Bibasal crackles
-
8/3/2019 Grand Rounds 2
15/57
Heart:Adynamic precordium,Apex beat at 5th left ICS, AAL,Bradycardic, regular rhythm,no murmur
-
8/3/2019 Grand Rounds 2
16/57
Abdomen: flabby Normoactive bowel sounds 8 cm liver span midclavicular line and 5 cm
midsternal (+) epigastric tenderness no guarding and rigidity
-
8/3/2019 Grand Rounds 2
17/57
Extrenities:
(+) Bipedal edema grade 1, full and equal pulses
-
8/3/2019 Grand Rounds 2
18/57
66year old female
Difficulty of breathing
Chest pain
Diaphoresis Epigastric pain
Engorged neck vein
Bibasal crackles
Bipedal edema
-
8/3/2019 Grand Rounds 2
19/57
Acute Coronary Syndrome, CHF, FC II
-
8/3/2019 Grand Rounds 2
20/57
Aortic dissection
Pneumothorax GERD
Pulmonary Embolism
-
8/3/2019 Grand Rounds 2
21/57
DISEASE ENTITY RULE - IN RULE-OUT
Aortic dissection Chest pain Tearing painMurmurBruitsUnequal pulsesTrop-I:negatiive
Pneumothorax Chest painDypnea
Diminished breathsounds over hemithoraxTrop-I: Negative
GERD Retrosternal chest pain Nausea nd vomitingTrop-I Negative
Pulmonary embolism
-
8/3/2019 Grand Rounds 2
22/57
On Admission:
Low salt and low fat diet
Diagnostic: 12 Lead ECG
Troponin I
CXR-PA Na, K, Ca, Mg
Lipid profile, ALT and Creatinine
CBC with PC
Urinalysis IVF w/ D5W
Dopamine drip
-
8/3/2019 Grand Rounds 2
23/57
-
8/3/2019 Grand Rounds 2
24/57
WBC 8.1
Hemoglobin 114
Hematocrit 0.38
Platelet count 145
Neutrophils 59
41 26
-
8/3/2019 Grand Rounds 2
25/57
-
8/3/2019 Grand Rounds 2
26/57
-
8/3/2019 Grand Rounds 2
27/57
Medication: Fondaparinux 2.5 mg sq, OD
ASA 80 mg 4 tabs Stat chewed then 1 tab OD
Clopidogrel 75mg 4 tabs Stat chewed then 1 tab OD
Atorvastatin 80mg 1 tab @ HS
Lactulose 30cc @ HS
-
8/3/2019 Grand Rounds 2
28/57
2nd Hospital day
S> Decrease chest pain, (+) Bipedal edema
O> BP: 90/50 - 120/70 CR: 84 bpm RR: 18cpm
A> Acute Coronary Syndrome, NSTEMI vs UA, CHF,FC II
P> 2D Echo once stable Repeat 12-L ECG Start Trimetazidine 35mg/tab, BID Fondaparinux 2,5 mg SQ OD Furosemide 20 mg IV q8 provided SBP >100mmhg Spironolactone 25 mg tab, OD Lanzoprazole 30 mg tab, OD continue Dopamine drip
-
8/3/2019 Grand Rounds 2
29/57
-
8/3/2019 Grand Rounds 2
30/57
Labs:
Trop I: Positive
Chole: 5.3 mmol/L Trigly: 1.63 mmol/L N HDL: 0.9 mmol/L LDL: 3.67 mmol/L VLDL: 0.7 mmol/L Chol/dHD: 6.18
Urea: 5.4 mmol/L
Crea: 101 umol/L K: 4.1 mmol/L Calcium: 2.54 mmol/L
ALT:
-
8/3/2019 Grand Rounds 2
31/57
3rd Hospital day
S> (-) Chest pain , (-) DOB, (+) bipedal edema,grade 1
O> BP: 95/50- 115/64 mmhg CR:80 bpm RR:22
cpm A> Acute Coronary Syndrome, NSTEMI, in SR,
CHF, FC II
P> Continue Dopa drip
-
8/3/2019 Grand Rounds 2
32/57
Labs:
Color Yellow
Transparency Sl. turbid
Reaction 6
Specific gravity 1.020
Pus cells 1-2/hpf
RBC 0-1/hpf
Epithelial cells Few
Bacteria Few
Albumin negative
Sugar negative
-
8/3/2019 Grand Rounds 2
33/57
4th Hospital day:
S> BP: 90/50 mmhg CR: 60 bpm RR: 25 cpm
O> (-) chest pain, , (-) DOB, bipedal edema
A> Acute Coronary Syndrome, NSTEMI, in SR,CHF, FC II
P> Repeat 12-L ECG
Furosemide @ 20 mg IV q 8hrs
-
8/3/2019 Grand Rounds 2
34/57
-
8/3/2019 Grand Rounds 2
35/57
Magnesium 0.68 N
Na 131 N
K 4.03 N
-
8/3/2019 Grand Rounds 2
36/57
5th Hospital day:
S> BP: 140/80 mmhg CR: 65 bpm RR: 23 cpm
O> (-) chest pain, , (-) DOB, bipedal edema
A> Atherosclerotic heart disease, Acute CoronarySyndrome, NSTEMI, in SR, CHF, FC II
P> Continue medication May transfer to cardio ward
shift furosemide IV to 20mg/tab
12-L ECG
-
8/3/2019 Grand Rounds 2
37/57
-
8/3/2019 Grand Rounds 2
38/57
7th Hospital day
A> Acute Coronary Syndrome, NSTEMI, in SR, CHF, FC II
P>Discharged improved THM:
Trimetazedine 350mg, BID
Spironolactone 25mg/tab, tab OD
ASA 80mg/tab, OD
Clopidogrel 75mg/tab, OD
Atorvastatin 80mg/tab, OD HS
Lansoprazole: 300 mg OD x 7 days
Lactulose 30cc OD @ HS
-
8/3/2019 Grand Rounds 2
39/57
-
8/3/2019 Grand Rounds 2
40/57
-
8/3/2019 Grand Rounds 2
41/57
IHD
CAD(stable angina) ACS
NSTEMI(Trop-I: +)
STEMI
No ST ElevationST Elevation
Unstable Angina
(No ST Elevation ACS)
-
8/3/2019 Grand Rounds 2
42/57
Imbalance between myocardial oxygen supply anddemand.
Or by increase in myocardial oxygen demandsuperimposed on an atherosclerotic plaque.
-
8/3/2019 Grand Rounds 2
43/57
1. Plaque rupture or erosion w/ superimposednonocclusive thrombus.
2. Dynamic Obstruction
3. Progressive mechanical obstruction
4. 2ndry UA related to increased myocardial oxygendemand and/or decreases supply
-
8/3/2019 Grand Rounds 2
44/57
Clinical History/P.E.
Echocardiogram: ST-segment depression > 0.5 mm (0.5 mv)in two or more contigous leads.
Biochemical markers: rise in Troponins occurs after 3 to 4hours. And may persist elevated up to 2 weeks.
Echocardiography
Imaging of the coronary anatomy
-
8/3/2019 Grand Rounds 2
45/57
Chest pain Dyspnea
Epigastric dyscomfort
Diaphoresis
Pale cool skin
Sinus tachycardia
Basilar rales
Hypotension
-
8/3/2019 Grand Rounds 2
46/57
Grading of Angina Pectoris
According to CCS Classification
Class Description of Stage
I Ordinary physical activity does not cause angina
II Slight limitation of ordinary activity.
-
8/3/2019 Grand Rounds 2
47/57
Grading of Angina Pectoris
According to CCS Classification
III Marked limitations of ordinary physical activity.
IV Inability to carry on any physical activity withoutdiscomfort.
-
8/3/2019 Grand Rounds 2
48/57
Anti-ischemic agents Anticoagulants
Antiplatelets
Coronary revascularization Long term management
-
8/3/2019 Grand Rounds 2
49/57
Medical treatment: Must be placed at bed rest w/continous ECG monitoring for ST-segment deviationand cardiac rhythm.
Oxygen
Anti-ischemic treatment: Nitrates: given sublingually
Anti coagulant: Fondaparinux 2.5 SQ,
Enoxaparin 1 mg/kg subcutaneously q12
-
8/3/2019 Grand Rounds 2
50/57
Antiplatelets:
ASA, initial dose of 160-325 mg followed by 75-100mgOD
Clopidogrel, Loading dose of 300-600mg followed by75mg daily.
Fundaparinux:
-
8/3/2019 Grand Rounds 2
51/57
pCatalyzes factor Xa inhibition by antithrombin and does notenhance the rate of thrombin inhibition. Is cleared unchanged via kidneys , it is contraindicated in
patients w/ a creatinine clearance of < 30 ml/min.
ASA: antithrombotic effect by irreversely acetylating andinhibiting paltelet cyclooxygenase (COX)1.
Clopidogrel: Antiplatelet The drug irreversibly inhibits the P2Y subtype of ADP receptor,
which is important in aggregation of platelets and cross-linkingby the protein fibrin. The blockade of this receptor inhibitsplatelet aggregation by blocking activation of the glycoproteinIIb/IIIa pathway.
Atorvastatin: inhibit HMG reductase.
-
8/3/2019 Grand Rounds 2
52/57
Lactulose: The metabolites of lactulose draw water into the
bowel, causing a cathartic effect through osmotic action.
Trimreazidine: an anti-ischemic metabolic agent, whichimproves myocardial glucose utilization through inhibition
of fatty acid metabolism, also known as fatty acid oxidationmetabolism.
Furisemide: loop diuretic. By inhibiting the transporter, theloop diuretics reduce the reabsorption of NaCl
-
8/3/2019 Grand Rounds 2
53/57
Lanzoprazole: Proton pump inhibitor (PPI) whichprevents the stomach from producing gastric acid.
Dopamine: acting on the sympathetic nervous system,producing effects such as increased heartrate and blood pressure.
-
8/3/2019 Grand Rounds 2
54/57
Long term management:
Recommendation for lipid lowering therapy: Statins are recommended for all NSTE-ACS patient,
irrespective of cholesterol levels, in the aim of achievingLDLc < 2.6 mmol/L.
Use of beta-blocker BB are appropraite anti-ischemic therapy and may help
decrease triggers for MI.
Use of ACE-inhibitors Recommended for plaque stabilization.
-
8/3/2019 Grand Rounds 2
55/57
Long term management:
Recommendation for lipid lowering therapy: Statins are recommended for all NSTE-ACS patient,
irrespective of cholesterol levels, in the aim of achievingLDLc < 2.6 mmol/L.
Use of beta-blocker BB are appropraite anti-ischemic therapy and may help
decrease triggers for MI.
Use of ACE-inhibitors Recommended for plaque stabilization.
-
8/3/2019 Grand Rounds 2
56/57
Long term management:
Antiplatelet: therapy, recommended to becombination of aspirin and clopidogrel for at 9-12
months.
-
8/3/2019 Grand Rounds 2
57/57
Thank You