This document presents a case study of a 28-year-old male who presented to the emergency department with chest pain. His initial troponin level was negative but later increased. His ECG showed ST elevations. He was diagnosed with an ST elevation myocardial infarction (STEMI) based on his symptoms, elevated troponin level, and ECG changes. He was admitted and managed medically with aspirin, clopidogrel, heparin, oxygen, nitroglycerin, and morphine as needed. He had an uneventful recovery and was discharged after 5 days.

1. INTERNAL MEDICINE
Case Presentation
RandolphTulsie
Georgetown Public Hospital Corporation
1

2. Case Outline
The Patient is a 28 year old Male with chief complaint of Chest
Pain which started at 9:00am that day.The Patient refers that
he had a sudden onset of Central Chest Pain (6/10) along with 2
episodes ofVomiting.
He went to a private Institution where a troponin assay was
done (11:00 am) which came back negative. Patient was
referred to GPHC and at the time of presentation to A/E had no
complaints
He has no previous medical or surgical history. He refers his
mother died of a Myocardial Infraction some years ago.
Physical Examination was unremarkable.
2

3. 28 yr old
Male
Chest
Pain
Family
Hx of MI
Vomiting
Resp: 27 Bpm
Pulse: 82 bpm
BP: 158/62 mmHg
O2 Sat: 95%
Temp: 98.2 F
3

4. Differential Diagnosis for Severe Chest
Pain
CRITICAL
• Acute Coronary
Syndromes
• STEMI
• Non-STEMI
• Unstable
angina
• Aortic Dissection
• Cardiac
Tamponade
• Pulmonary
Embolism
• Tension
Pneumothorax
Emergent
• Pericarditis
• Myocarditis
• Pneumothorax
• Mediastinitis
• Cholecystitis
• Pancreatitis
• Cocaine chest
pain
Non Emergent
• Stable angina
• Asthma exacerbation
• Valvular Heart
Disease
• Pneumonia
• Pleuritis
• Tumor
• Esophageal Spasm
• Gastroesophageal
Reflux Disease
(GERD)
• Peptic Ulcer Disease
• Biliary Colic
• Rib Fracture
• Chostochondirits
• Panic attack
4

5. Investigations
• ST segment elevation in leadsV2,V3,
AVF
• SinusTachycardia
ECG
• Troponin = 65 ng/dL ( 20:35hrs)
Cardiac
Markers
• No Structural AbnormalitiesECHO
• Leukocytosis
• Elevated ESR/CRP
BloodTest 5

6. 6

7. Our Diagnosis
ST elevation
Myocardial
Infarction
Positive
Troponin I
ST elevation
on ECG Leads
Chest Pain
7

8. Acute Coronary
Syndrome
8

9. Definition
• Acute coronary syndrome is a term used to describe a
range of conditions associated with sudden, reduced
blood flow to the heart.
• It is almost always associated with rupture of an
atherosclerotic plaque and partial or complete
thrombosis of the infarct-related artery.
• ACS leads to myocardial ischemia and eventually necrosis
which results in compromised cardiac functioning
9

10. Types
• Non OcclusiveThrombus
• Normal ECG
• No Cardiac Enzymes
UnstableAngina
• Partial CoronaryArtery Occlusion
• PartialThickness Necrosis (+Ti, CKMB)
• ST depression/T wave Inversion
Non ST Elevation
Myocardial
Infraction
• Complete Ischemia
• FullThickness Necrosis ( ++Ti, CK MB)
• ST Elevation
ST Elevation
Myocardial
Infraction 10

11. Pathophysiology
Rupture of
CoronaryArtery
Plaque
Platelet
Aggregation to
Fibrous Cap
Thrombus
Formation
CoronaryArtery
Occlusion and
Vasoconstriction
ISCHEMIANECROSIS
AN INCREASE IN OXYGEN DEMAND OF A STABLEANGINA
CAN ALSO RESULT IN ACS; OCCURING IN EXERTION
11

12. 12

13. Clinical Manifestations
• Chest Pain, Pressure or Heaviness
• Palpitations
• Pain Radiating to Neck, Jaw, Left Arm, Back and Epigastric Region
• Syncope
• Shortness of Breath
• Nausea andVomiting
• Diaphoresis and Decreased ExerciseTolerance 13

14. Investigations
• ST Depression, Elevation;T wave Inversion,
Arrhythmias, LBBBECG
• CK-MB
• Troponin ICardiac Markers
• Pulmonary edema
• Cardiomegaly
• Pneumonia
• Thoracic aneurysm
CXR
• Reduced Ejection fraction
• Ventricular Wall abnormalities
• Complications ( MR, LV Rupture)
ECHO
• Leukocytosis
• Elevated ESR/CRP
• Hyperglycemia
BloodTest 14

15. 15

16. Management
16

17. Management
ImmediateTherapy : In Hospital Within 12 hrs
CLASS DRUG RATIONALE
Analgesics Morphine Sulphate 5–10 Mg
Or Diamorphine
2.5–5 Mg)
Lower adrenergic drive reduce
vascular resistance, and
susceptibility
To ventricular arrhythmias
Antiplatelet
therapy
75–325 Mg Aspirin +
Clopidogrel 600 Mg
immediately Followed By
150 Mg Daily For 1Week
25% relative risk reduction in
mortality
Reduces recurrent ischemia
Anticoagulants Low-molecular-weight
Heparin
1 Mg/KgTwice Daily For 8
Days
Prevents re-infarction in the
absence of reperfusion therapy
Anti-Anginal
therapy
• Sublingual Glyceryl
Trinitrate (300–500 Μg)
• Β-blockers - Atenolol 5–
10 Mg
• Calcium Channel
Antagonist Nifedipine
Or Amlodipine
Relieve pain,
Reduce arrhythmias and improve
short-term mortality
In patients who present within 12
hours of the onset of
Symptoms 17

18. Management
Percutaneous Coronary Intervention
• Immediate emergency reperfusion therapy has no
demonstrable benefit in patients with non-ST segment
elevation MI and thrombolytic therapy may be harmful.
• In ST segment elevation acute coronary syndrome;
Immediate reperfusion therapy restores coronary artery
patency, preserves left ventricular function and improves
survival.
• Primary PCI is more effective than thrombolysis for the
treatment of acute MI. Death, non-fatal re-infarction and
stroke are reduced from 14% with thrombolytic therapy
to 8% with primary PCI 18

19. 19

20. 20

21. 21

22. 22

23. Management
LongTermTherapy
Lifestyle
modification
• Diet (weight
control, lipid-
lowering
Mediterranean
diet)
• Cessation of
smoking
• Regular exercise
Secondary prevention
drug therapy
• Antiplatelet
therapy (aspirin
and/or clopidogrel)
• β-blocker
• ACE inhibitor/ARB
• Statin
• Additional
therapy for control
of diabetes and
hypertension
• Mineralocorticoid
receptor
antagonist
Others
• Rehabilitation
• Implantable
cardiac
defibrillator
23

24. Prognosis
• In almost one-quarter of all cases of MI, death occurs
within a few minutes without medical care.
• Half the deaths occur within 24 hours of the onset of
symptoms and about 40% of all affected patients die
within the first month.
• The prognosis of those who survive to reach hospital is
much better, with a 28-day survival of more than 85%.
Patients with unstable angina have a mortality of
approximately half that of those patients with MI
REMEMBERTIME IS MUSCLE SO ACT FAST
24

25. Back to Our Patient
This Patient suffered an Inferior STEMI and was effectively
managed in CICU with the following medication:
• Atorvostatin 80mg PO Nocte
• Aspirin 81mg PO OD
• Clopidigrel 75mg PO OD
• Inj Heperin 17000 U Sc BD
• O2 via F/M PRN
• GTN Po SL PRN
• Inj Morphine 5mg IV PRN
25

26. His Outcome
.
• Patient had an uneventful recovery, spending five days in
the hospital before being discharged and referred to a
private institution for long term management
26

27. THANKYOU
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28. References
• Boon, N. A., & Davidson, S. (2006). Davidson's principles
& practice of medicine. Edinburgh: Elsevier/Churchill
Livingstone.
• Kasper, D. L., Hauser, S. L., Jameson, J. L., Fauci, A. S.,
Longo, D. L., Loscalzo, J., & Harrison,T. R. (2015).
Harrison's principles of internal medicine. NewYork:
McGraw-Hill Education.
• http://www.mayoclinic.org/diseases-conditions/acute-
coronary-syndrome/home/ovc-20202307
• http://emedicine.medscape.com/article/1910735-
overview
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