- A 45-year-old man presented to the emergency department with severe central chest pain for 3 hours. He has a history of diabetes mellitus. - Examination found elevated blood pressure and heart sounds within normal limits. Investigations showed elevated troponin levels and ECG changes consistent with an ST elevation myocardial infarction involving the right ventricle. - The patient was diagnosed with an acute ST elevation myocardial infarction complicated by right ventricular infarction and acute left ventricular failure. He received treatment including streptokinase, aspirin, beta blockers, and insulin for his diabetes.

1. Critical Case Presentation

2. A 45-YEAR MAN WITH SEVERE
CENTRAL CHEST PAIN
PRESENTER
DR.MD.SAJJAD SAFI
PHASE-B,MD CARDIOLOGY
BLUE UNIT
BSMMU

3. PARTICULARS
• Name :Md.Shirajul Islam
• Age :45 years
• Address :Rahmatgonj, Chachok Bazar
• Occupation: Businessman
• Married
• Date of admission:10-12-2016 @6:10pm
• Date of examination:10-12-2016 @09:30pm

4. Chief complaints
• Severe central chest pain for 3 hrs

5. History of present illness
• Diagnosed case of Diabetes Mellitus(DM) for 2 yrs
• Chest pain:
– For 3 hrs
– Retrostenal central chest pain
– sudden onset and progressive (crescendo type)
– Very severe in nature
– Associated with excessive sweating and palpitation
– Radiating to right side of chest
– And relieved by sublingual nitroglycerine spray

6. Conti…
• No h/o :Fever,Cough, LOC or Chest trauma
• H/o DM for 2 yrs on oral medication
• H/o smoking for 10 yrs
• No h/o Hypertension(HTN)

7. On examination
• Anxious and restlessness
• 0riented and able to talk
• Mildly anemic ,no edema and not dehydrated
• All limbs are warm

8. • Pulse rate : 60 beats/min
• Blood Pressure: 180/120mmHg
• Temperature : Afebrile
• Respiration : 18/min
• Spo2 :90-92% with high flow o2
• JVP :Not raised

9. Systemic examination
• Cardiovascular :S1 and S2 audible,no murmur
• Respiratory :24/min with B/L basal crepts
present
• Other systems: Revealed no abnormality

10. INVESTIGATIONS
• ECG
• RBS
• ELECTROLYTES
• TROPONIN-I
• ECHO(2D and M-mode)

11. ECG

12. Lab Reports
10/12/2016 11/12/16
Troponin I 0.06 ng/ml 175.64 ng/mL
Sodium 140 mmol/L 139 mmol/L
Potassium 4.9 mmol/L 3.7 mmol/L
S.creatinine 0.96 mg/dl 1.13 mg/dL
RBS 23.9 mmol/L 19.40 mmol/L

13. ECHO
• Infero-septal wall hypokinetic
• Free wall:basal and mid akinetic-akinetic
• Fair LV systolic function
• Impaired RV function
• EF=58%

14. Diagnosis
• Acute STEMI(inf with RV infarction)
• Acute left ventricular failure(ALVF)
• Hypertension emergency
• Diabetes mellitus(DM)

15. Management
• Complete bed rest
• Propped up position
• O2 inhalation with 2L/min throu’ nasal cannula
• Diet diabetic with chart
• Inj. Frusomide (Lasix) 1amp iv stat then sos
• Inj. GTN 1 amp(50mg)+40mL NS @ 0.3mL/hr and
titrate
• Inj. Morphine 3mg iv stat then sos(1amp+14D/W)
• Inj. Prochlorperazine(Vergon) 1 amp iv stat

16. Streptokinase injection
• Hold till Blood pressure(BP) under controlled
with iv GTN
• Started with BP(160/95)mm Hg
• Inj.STK 1.5 IU throu’ syringe pump over
60mins

17. After STK injection

18. Conti…
• Antiplatelets: Tab.Aspirin,(75mg) &
clopidregrel (75mg)
• Statins: Tab.Atovastatin,(40mg)
• ACE inhibitor : Tab.Ramopril ,(2.5)
• PPIs: Tab.Rabeprazole,(20mg)
• Heparin :Low molecular heparin(1mg/kg)
• Insulin : Regular insulin sliding scale
• Anxiolytics: clonazepam 1mg at night

19. Next plan
• ECHO
• Sub minimal ETT
• CAG

20. Contraindications and Cautions for Fibrinolytic
Therapy in STEM
• Absolute contraindications
– Any prior ICH
– Known structural cerebral vascular lesion(e.g., AV malformation)
– Known malignant intracranial neoplasm (primary or metastatic)
– Ischemic stroke within 3 mo (EXCEPT acute ischemic stroke
within 4.5 h)
– Suspected aortic dissection
– Active bleeding or bleeding diathesis (excluding menses)
– Significant closed-head or facial trauma within 3 mo
– Intracranial or intraspinal surgery within 2 mo
– Severe uncontrolled hypertension (unresponsive to emergency
therapy)
– For streptokinase, prior treatment within the previous 6 mo

21. • Relative contraindications
– History of chronic, severe, poorly controlled hypertension
– Significant hypertension on presentation (SBP >180 mm
Hg or DBP >110 mm Hg)
– History of prior ischemic stroke >3 mo
– Dementia
– Known intracranial pathology not covered in absolute
contraindications
– Traumatic or prolonged (>10 min) CPR
– Major surgery (<3 wk)
– Recent (within 2 to 4 wk) internal bleeding
– Noncompressible vascular punctures
– Pregnancy
– Active peptic ulcer
– Oral anticoagulant therapy

22. THANK YOU