Acs – inferior wall myocardial infarction. by abhimanyu

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A very informative case on ACS for budding Clinical pharmacists, it covers Classification of ACS with types of MI's as well pharmaceutical care plan for the management of ACS

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Acs – inferior wall myocardial infarction. by abhimanyu

  1. 1. Case on ACS – Inferior wall Myocardial Infarction By: Abhimanyu Parashar 5th Pharm.D 9/5/2013 1
  2. 2. ACS 9/5/2013 2
  3. 3. 9/5/2013 3
  4. 4. Myocardial infarction 0 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 breath 3. Nausea 4. Vomiting 5. Palpitations 6. Sweating 7. Anxiety 8. Fatigue 9/5/2013 4
  5. 5. Classification 0 There are two basic types of acute myocardial infarction based on pathology: 1. Transmural: 0 Anterior 0 Posterior 0 Inferior 0 lateral 0 Septal 2. Subendocardial: 0 Involving a small area in the subendocardial wall of the left ventricle, ventricular septum, or papillary muscles 9/5/2013 5
  6. 6. 9/5/2013 6
  7. 7. 0 A 2007 consensus document classifies myocardial infarction into five main types 1. Type 1 – Spontaneous myocardial infarction 2. Type 2 – Myocardial infarction secondary to ischemia 3. Type 3 – Sudden unexpected cardiac death, including cardiac arrest 4. Type 4 – Associated with coronary angioplasty or stents 5. Type 5 – Myocardial infarction associated with CABG 9/5/2013 7
  8. 8. 0 Age : 63 years 0 IP No. 1289064 0 Unit : Vikram Hospital (Dept. Cardiology) 9/5/2013 8
  9. 9. Reasons for admission C/O: 0 Acute onset of Retro-sternal burning sensation 0 Mild sweating 0 Giddiness 9/5/2013 9
  10. 10. 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 9/5/2013 10
  11. 11. General examination 0 BP : 120/80 mmHg Pulse : 80 BPM 0 CVS: S1S2 + 0 ECG: Inferior Wall MI 0 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. 9/5/2013 11
  12. 12. DAY 1 0 BP : 120/80 mmHg Pulse : 80 BPM 0 CVS :S1S2 + 0 2D ECHO: IHD, Hypo-kinetic basal Inferio-Posterior wall Ejection fraction: 50 % Troponin I: +ve Impression: ACS 0 At 9 PM : GC stable , No Angina/ Dyspnea Vitals : Normal 0 ADV: CST CBG (BB): 177 mg/dl CBG (BL): 231 mg/dl CBG (BD): 102 mg/dl 9/5/2013 12
  13. 13. 9/5/2013 13
  14. 14. Lab Reports Biochemistry 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 019/5/2013 14
  15. 15. 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 9/5/2013 15 Inj. Actrapid if sliding scale > 200 mg/dl T. Isosorbide Dinitrate 2.6 mg SL 1-1-0
  16. 16. DAY 2 0 BP : 130/80 mmHg Pulse: 88 BPM 0 CVS: S1S2 + , SSM + RS: Clear 0 ADV: CST, CAG counseling At 5 PM: GC fair , No Angina/ Dyspnea 0 Troponin I: +ve 0 ADV: CST and CAG after RFT RBG : 231 mg/dl CBG (BB): 172 mg/dl CBG (BL): 148 mg/dl CBG (BD): 245 mg/dl 9/5/2013 16
  17. 17. Thrombolysis in Myocardial Infarction 9/5/2013 17
  18. 18. 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 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 18
  19. 19. DAY 3 0 BP : 120/80mmHg Pulse : 72 BPM 0 CVS : S1S2 + RS: NVBS + 0 RBS: 172 mg/dl CBG (BB) : 180 mg/dl 0 ADV: CAG and CST 0 CAG report: Triple vessel disease PTCA + stent of OM + LCX 0 Post CAG: TVD, No Angina/ Dyspnea Vitals: Normal 0 ADV : CST , Counseling for PTCA + stent of OM and CLX 9/5/2013 19
  20. 20. 9/5/2013 20
  21. 21. Coronary Angiography Reports 9/5/2013 21
  22. 22. Coronary Angiography Reports9/5/2013 22
  23. 23. 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 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/dl9/5/2013 23
  24. 24. DAY 4 0 BP : 120/80 mmHg Pulse : 80 BPM 0 CVS : S1S2 + 0 Post CAG – TVD 0 NO Angina/ Dyspnea 0 ADV: CST , Discharge 9/5/2013 24
  25. 25. 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 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 25
  26. 26. 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 _ + + + 26 T. Isosorbide Dinitrate 2.6 mg SL 1-1-0 + + + + Inj. Actrapid if sliding scale > 200 mg/dl SC
  27. 27. Discharge Medication DRUG 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 __ 9/5/2013 27 Total : 66 Rs/Day
  28. 28. PHARMACEUTICAL CARE PLAN 9/5/2013 28
  29. 29. 9/5/2013 29 0 SUBJECTIVE EVIDENCE: 1. Retro-sternal burning sensation 2. Mild sweating 3. Giddiness 0 OBJECTIVE EVIDENCE: 1. ECG: Inferior Wall MI 2. 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
  30. 30. Final Diagnosis ACS- Inferior wall MI with Triple Vessel Diseases with Hypertension and Type 2 Diabetes Mellitus 9/5/2013 30
  31. 31. Goals of Treatment 0 Short term goals : 1. Initial evaluation & stabilization 2. Relief of ischemic chest discomfort 3. Efficient risk stratification 4. Focused cardiac care 5. Early restoration of blood flow to the infarct-related artery to prevent infarct expansion. 6. Increase myocardial oxygen delivery 7. Prevention of death and other complications 9/5/2013 31
  32. 32. 0 Long term goals: 1. Prevent complications and recurrences. 2. Reduce mortality and improve quality of life 9/5/2013 32
  33. 33. Treatment Options 9/5/2013 33 For Hypertension For IHD For 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
  34. 34. 9/5/2013 34
  35. 35. 9/5/2013 35 0 Signs and symptoms were reduced by day 2 0 Lipid profile not done GOALS ACHIEVED Problems Identified
  36. 36. Monitoring Parameters 9/5/2013 36 0 Disease related : 1. Blood Pressure 2. ECG 3. 2D-ECHO 4. Blood Glucose levels 5. Hb A1c 6. Lipid Profile 0 Drug related : 1. Platelets count 2. Blood pressure
  37. 37. Patient Counseling 9/5/2013 37
  38. 38. About Disease 9/5/2013 38
  39. 39. 9/5/2013 39
  40. 40. About PTCA 0 Advantages: 1. It can be done under local anesthesia. 2. The procedure is faster. Recovery period is shorter and less painful 3. The procedure does not leave a noticeable scar 4. 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. 9/5/2013 40
  41. 41. 0 Disadvantages: 1. Coronary angioplasty can be used only if one or two arteries are affected 2. It cannot be used in arteries that cannot be reached by the catheter 3. It may not be effective against very hard atherosclerotic plaques. 4. Restenosis may occur, especially if a stent is not placed during the procedure 9/5/2013 41
  42. 42. About Medications 0 Name and purpose 0 Dose and frequency 0 Medication adherence 0 Possible adverse effects 0 Missed dose 9/5/2013 42
  43. 43. About life style modification Thursday, September 05, 2013 43 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 recommendations 0 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
  44. 44. 0 Physical activity: advise gradual increase in activity 1. 2wk. after Ml stroll in garden or street 2. 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 Ml 2. Light manual workers 6-8wk. after uncomplicated Ml 3. Heavy manual workers 3months after uncomplicated Ml 9/5/2013 44
  45. 45. 0 Monitoring health: continue regular reviews at least annually for lifelong. Check for symptoms and signs of cardiac dysfunction (breathlessness, palpitations, angina). 0 Secondary prevention 0 Smoking cessation 0 Hypertension ,Check BP and refer physician if >140/90 0 Alcohol withdrawl. 9/5/2013 45
  46. 46. Thursday, September 05, 2013 46 Fat 20–35% of total caloric intake Saturated fat < 7% of total calories <200 mg/day of dietary cholesterol Two 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
  47. 47. THANK U 9/5/2013 47

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