ccd - inferior wall Mi

1. Clinical Case
Discussion
Dr Shinde Viraj Ashok
Jr – 1
Department of Pharmacology
Inferior Wall Myocardial Infarction

2. Patient profile
• Name – Shivkumar Apture
• Age – 47 yrs
• Sex – M
• Registration no – 11674729
• Ward – ICCU
• Date of admission – 3 march 2015 at
• Diagnosis – Inferior wall myocardial infarction

3. 3 march 2015
Symptoms
• Compliants of chest pain
& uneasiness since last
night
• No H/O vomiting
• ECG – q wave & ST
elevation in lead 3 & aVf
with reciprocal changes
Treatment received
• Inj LMWH 0.6 cc s/c BD
• Tb aspirin 300mg stat f/b
75mg OD
• Tb clopitab 300mg stat f/b
75mg OD
• Tb atorvas 40 mg stat
• Tb envas 5mg OD
• Tb met XL 25 mg 1-0-0

4. Admission notes
3 march 2015 at 1.45 pm
• A 47 yrs male patient was brought by relatives with
c/o chest pain since 2 days
• No H/O breathlessness, palpitation , syncopal attack ,
oedema of feet
• k/c/o systolic hypertension since 6 months on regular
treatment [details were not available]
• O/E GC - moderate
• Pulse - 64 bpm
• JVP – not raised

5. 3 march 2015 at 1.45pm
• Systemic examination
CVS – heart sounds heard normal
Chest – clear
P/A – soft
CNS – conscious oriented
ECG – ST elevated & q wave in lead 2 , 3 & avf
ST depressed in lead 1 , aVl , V4 to V6
Diagnosis - Evolved inferior wall myocardial infarction

6. Treatment
3 march 2015 at 1.45pm
• Tb aspirin 75 mg OD
• Tb clopitab 75mg OD
• Tb atorvas 40mg OD
• Tb sorbitrate 10 mg BD
• Inj LMWH 0.6 cc s/c BD
• Tb rantac 150mg BD

7. s/b SP 2
3 march 2015 at 2 pm
Patients vitals
• Oriented
• HS – normal
• Chest – clear
• P/A- normal
• ECG – sinus
bradycardia, ST elevated
& q’s in lead 2 , 3 & avf
Traetment given
• Inj atropine sos
• Ct all

8. s/b Lecturer
3 march 2015 at 8pm
Patients vitals
• Pulse - 60 bpm
• GC – moderate
• Minimal chest pain
• No signs of heart failure
• Chest – clear
• HS – normal
• Conscious
Treatment
• With hold Tb met XL
• Tb aspirin 75 mg OD
• Tb clopitab 75mg OD
• Tb atorvas 40mg OD
• Tb sorbitrate 10 mg BD
• Inj LMWH 0.6 cc s/c BD
D1
• Tb rantac 150mg BD
• Inj atropine 2 cc sos

9. Investigations 3/3/2015
 T protein – 7.8gm%
 T bilirubin –0.8mg%
 Sr alkaline phosphatase – 92 IU/L
 SGOT –179 IU/L
 SGPT – 69 IU/L
 Sr urea – 57 mg/dl
 Sr creat – 1 mg/dL
 Sr cholestrol – 291mg%

10. s/b Resident
4/3/2015 at 8am
Patients vitals
• GC – moderate
• Afebrile
• Pulse – 70bpm
• BP – 110/70 mm of Hg
• Chest – clear
• CVS – HS normal
• P/A – soft
• Conscious oriented
Treatment
• Inj LMWH 0.6 cc s/c BD
D2
• Tb aspirin 75 mg OD
• Tb clopitab 75mg OD
• Tb atorvas 10mg HS
• Tb sorbitrate 10 mg TDS
• Tb rantac 150mg BD
• Inj atropine 2 cc sos

11. s/b Lecturer
4/3/2015 at 9 am
Patients vitals Treatment
• Ct all
• Adv - CPK - MB
• C/O severe chest pain
• GC – moderate
• Afebrile
• Pulse – 80bpm
• Chest – clear
• CVS – HS normal
• P/A – soft
• Transfer patient to ICCU

12. Transfer out notes from ward
to ICCU 4/3/15 at 9am
• C/O Inferior wall
myocardial infarction
Treatment
• Inj LMWH 0.6 cc s/c BD D2
• Tb aspirin 75 mg OD
• Tb clopitab 75mg OD
• Tb atorvas 10mg HS
• Tb sorbitrate 10 mg TDS
• Tb rantac 150mg BD
• Inj atropine 2 cc sos
• Inj NTG 1.2 mg in 1 RL drip

13. s/b Lecturer ICCU
4/3/2015 at 10.45am
• GC – moderate
• Afebrile
• Pulse - 88 bpm regular
• RR – 20 cpm
• RS - AEBE
• No signs of heart failure
• Chest – clear
• HS – normal
• Conscious oriented
Patients vitals Treatment
• Inj LMWH 0.6 cc s/c BD D2
• Tb aspirin 75 mg OD
• Tb clopitab 75mg OD
• Tb atorvas 10mg HS
• Tb sorbitrate 10 mg TDS
• Tb rantac 150mg BD
• Inj atropine 2 cc sos
• Inj NTG 1.2 mg in 1 RL drip

14. s/b SP 2
4/3/2015 at 10.45am
• GC – Moderate
• Afebrile
• Pulse – 80 bpm
• S1S2 - heard
Treatment
• Tb ranolazine 500mg BD
• Tb met XL 25 mg OD
• Tb sorbitrate
Patients vitals

15. Investigations 4/3/2015
 Hb – 12.3gm%
 TLC – 9400cumm
 Platelets –adequate
 Triglycerides – 239 mg%
 Sr cholestrol – 213 mg%
 Sr HDL cholestrol – 46 mg%
 Sr LDL cholestrol – 111mg%
 T protein – 7.6gm%
 T bilirubin –1.4mg%
 Sr alkaline phosphatase – 103 IU/L
 SGOT –141 IU/L
 SGPT – 65 IU/L
 Sr urea – 46 mg/dl
 Sr creat – 1.7 mg/dl
 Sr Na+-138 meq/L
 Sr K+ -4.1 meq/L

16. s/b Resident
5/3/2015 at 8 am
Patients vitals
• GC – moderate
• Afebrile
• Pulse - 86 bpm regular
• BP – 100/60 mm of Hg
• U/O - 1200ml
• RS - AEBE
• No signs of heart failure
• Chest – clear
• HS – normal
• Conscious oriented
Treatment
• Tb ranalozine 500mg BD
• Tb met XL 25 mg OD
• Inj LMWH 0.6 cc s/c BD D3
• Tb aspirin 75 mg OD
• Tb clopitab 75mg OD
• Tb atorvas 10mg HS
• Tb sorbitrate 10 mg TDS
• Tb rantac 150mg BD
• Inj atropine 2 cc sos

17. Patients vitals Treatment
• Ct all
s/b Lecturer ICCU
5/3/2015
• GC – moderate
• Afebrile
• Pulse - 100 bpm regular
• RS - AEBE
• P/A – soft
• Chest – clear
• HS – normal
• No signs of heart failure

18. s/b SP 2
5/3/2015 at 9am
Patients vitals
• Tb monotral sorbitrate
{asoral 20 mg BD}
Advice –
CPK MB – 41.3 U/L
Treatment
• GC – moderate
• Afebrile
• Pulse - 77 bpm regular
• RS - AEBE
• Chest – clear

19. s/b Resident
6/3/2015 at 8 am
Patients vitals
• GC – moderate
• Afebrile
• Pulse - 86 bpm regular
• BP – 100/60 mm of Hg
• U/O - 1200ml
• RS - AEBE
• No signs of heart failure
• Chest – clear
• HS – normal
• Conscious oriented
Treatment
• Tb ranalozine 500mg BD
• Tb met XL 25 mg OD
• Inj LMWH 0.6 cc s/c BD D4
• Tb aspirin 75 mg OD
• Tb clopitab 75mg OD
• Tb atorvas 10mg HS
• Tb sorbitrate 10 mg TDS
• Tb rantac 150mg BD
• Inj atropine 2 cc sos

20. s/b Resident
7/3/2015 at 8 am
Patients vitals
• GC – moderate
• Afebrile
• Pulse - 80 bpm regular
• BP – 100/60 mm of Hg
• RS - AEBE
• No signs of heart failure
• Chest – clear
• HS – normal
• Conscious oriented
Treatment
• Tb ranalozine 500mg BD
• Tb met XL 25 mg OD
• Inj LMWH 0.6 cc s/c BD
D5
• Tb aspirin 75 mg OD
• Tb clopitab 75mg OD
• Tb atorvas 10mg HS
• Tb sorbitrate 10 mg TDS
• Tb rantac 150mg BD

21. s/b Resident / Lecturer
8/3/2015 at 8 am
Patients vitals
• GC – moderate
• Afebrile
• BP – 100/60 mm of Hg
• RS - AEBE
• No signs of heart failure
• Chest – clear
• HS – normal
• Conscious oriented
Treatment
• Tb ranalozine 500mg BD
• Tb met XL 25 mg OD
• Tb aspirin 75 mg OD
• Tb clopitab 75mg OD
• Tb atorvas 10mg HS
• Tb sorbitrate 10 mg TDS
• Tb rantac 150mg BD

22. s/b Resident /Lecturer / SP2
9/3/2015 at 8 am
Patients vitals
• GC – moderate
• Afebrile
• Pulse - 80 bpm regular
• BP – 100/60 mm of Hg
• RS - AEBE
• No signs of heart failure
• Chest – clear
• HS – normal
• Conscious oriented
• Patient was shifted to super speciality
hospital for coronary angiography
Treatment
• Tb ranalozine 500mg BD
• Tb met XL 25 mg OD
• Tb aspirin 75 mg OD
• Tb clopitab 75mg OD
• Tb atorvas 10mg HS
• Tb sorbitrate 10 mg TDS
• Tb rantac 150mg BD

23. Discussion
 Myocardial Infarction –
Ischemic necrosis of a portion of the myocardium
due to sudden occlusion of a branch of coronary artery.

24. Standard treatment
• Depending on ST elevation myocardial infarction is
classified in to two types
• ST EMI – ST elevated MI
• Non STEMI – Non ST elevated MI
• Because in case of ST elevation patient is a candidate for
fibrinolysis

25. Standard treatment
• STEMI
Management
1. Aspirin
2. O2
3. Control of chest discomfort
a. Sublingual nitroglycerine
b. Morphine
c. Intravenous beta blockers followed by oral beta blockers
4. Primary percutaneous coronary intervention
OR
5. Fibrinolysis

26. • Inj low molecular weight heparin
• Based on extensive laboratory and clinical evidence that
thrombosis plays an important role in the pathogenesis of
this condition.
• Reduce significantly the composite endpoints of
death/nonfatal reinfarction and death/nonfatal
reinfarction/urgent revascularization compared with UFH
in STEMI patients who receive fibrinolysis..
• To prevent deep vein thrombosis & pulmonary embolism.

27. • Different manufacturers are providing LMWH in
different strengths
• Hence name of manufacturer along with dose in terms of
units should have been written but was not written.

28. Tb aspirin - 300mg stat followed by 75mg OD
• Use – Rational
• By inhibiting platelet aggregation lowers the incidence of
reinfarction
• Rapid inhibition of cyclooxygenase-1 in platelets followed
by a reduction of thromboxane A2 levels is achieved by
buccal absorption of a chewed 160 - 325 mg tablet in the
Emergency Department
• At lower doses TXA2 synthesis in platelets remain
inhibited while its synthesis and availability through other
cells like monocytes & eosinophils continues so initially
higher dose is given.

29. • Tb clopidogrel 75mg OD with or wihout initial loading
dose of 300mg
• Use – Rational
• Combination of clopidogrel & aspirin is synergistic in
preventing ischemic attacks
• Utilized for checking restenosis of stented coronaries.

30. • Tb atorvastatin 10 – 40mg/day
• Use – Rational
• Lowers LDL cholestrol.
• Potential cardioprotective effects .

31. • Tb enalapril 5- 20mg OD OR BD
• Use – Rational
• Reduce the mortality rate
• Mortality benefits are additive to those achieved with
aspirin and beta blockers
• Reduction in ventricular remodeling after infarction with
a subsequent reduction in the risk of CHF.
• Rate of recurrent infarction may also be lower in patients
treated chronically with ACE inhibitors after infarction.

32. • Tb metoprolol - 12.5 – 50 mg OD or BD
• Use – Rational
• Control pain effectively in some patients, presumably by
diminishing myocardial O2 demand and hence ischemia.
• Intravenous beta blockers reduce the risks of reinfarction
and ventricular fibrillation
• Incidence of sudden deaths post MI is less if continued
orally.

33. • Inj atropine - iv 2mg
• Use – Not rational.
• Because bradycardia was possibly caused by metoprolol
& heart rate of 6o bpm doesn’t require treatment or
discontinuation of beta blocker .

34. Nitrates
• Isosorbide dinitrate -5 -10mg sublingually
• Short acting – glyceryl trinitrate – begin with 5 micro
gram /min
• Use – use of either drug was rational but both
simultaneously Not rational
• diminish or abolishes chest discomfort
• decreasing myocardial oxygen demand - by lowering
preload
• Reduction in cardiac work – by after load reduction
• increasing myocardial oxygen supply - by dilating
infarct-related coronary vessels or collateral vessels

35. Nitrates (cont…)
• Tolerance – Attenuation of haemodynamic & antiischemic effects of
nitrates occurs in a dose & duration of exposure manner if they are
continously present in body
• Cross tolerance occurs among all nitrates.
• Therapy with nitrates should be avoided in patients who present
1. Low systolic arterial pressure (<90 mmHg) or in whom there is
clinical suspicion of right ventricular infarction
2. Inferior infarction on ECG,
3. Elevated jugular venous pressure
4. Hypotension
5. If patient has consumed sildenafil with in 24 hrs.

36. • Tb Ranolazine 0.5 - 1gm BD
• Use – Rational
• Reduction in cardiac overload in myocardium decreases
cardiac contractility & has cardioprotective effect
• Sparing of fatty acid oxidation during ischemia in favour
of more oxygen efficient carbohydrate oxidation by
inhibiting LC3KAT

37. Rationality
Not rational –
• No advice regarding diet was mentioned any where.
• Brand names were used.
• Short forms like met XL were used.
• At some places doses and route of administration were
missing.
• Instructions to the patient were also not written.

38. References
• Harrison's principles of internal medicine 18th edition
• The Goodman & Gillman’s ,The pharmacological basis
of therapeutics 12th edition
• Principles of pharmacology
S. K. Sharma, (2nd edition)