M. Shareef, a 65-year-old male with diabetes and coronary artery disease, presented with chest pain, breathlessness, fever and vomiting for 6 hours. He was admitted to the ICU where an ECG showed signs of a myocardial infarction. His treatment included aspirin, clopidogrel, streptokinase, morphine and metoclopramide. As a known diabetic and heart disease patient, he requires lifestyle modifications and optimized medical management to control his risk factors and prevent further cardiac complications.

2. MYOCARDIAL INFARCTION

3. Rabyya Kausar CMS# 9669
Ifrah Rizwan CMS# 9332
Sundas Safdar CMS# 9800
Zainab Ajaz CMS# 9981
Jasra Riffat Javed CMS# 9919

4. CONTENTS
Treatment Algorithm

5. CASE STATEMENT
M. Shareef is a 65 years old male patient having 76 kg weight from Abottabad. He is a
known case of diabetic patient since 12 years and Coronary artery disease for the last 2
years. He was admitted to hospital with the chief complaint of chest pain and
breathlessness for the last 6 hours. Patient had an episode of vomiting. He was
conscious and well oriented and overall health state was weak . Past medications
include Metformin 500mg TID. Patient was immediately admitted in ICU. Within 10
mins, ECG was performed and based upon diagnosis Oxygen & Cardiac rhythm
monitoring was performed. Further his management includes Aspirin 300mg PO,
Clopidogrel 600mg PO followed by 150mg daily for 1 week and 75mg daily thereafter,
Streptokinase 1 MIU/hr, Inj Morphine, Inj Metoclopromide I.V Stat 5mg/ml.

6. INTRODUCTION

7. DEFINITION
MI is defined by the demonstration of
myocardial cell necrosis due to significant and
sustained ischemia. It is usually, but not
always, an acute manifestation of
atherosclerosis-related coronary heart disease.
MI results from either coronary heart disease,
which implies obstruction to blood flow due to
plaques in the coronary arteries or, much less
frequently, to other obstructing mechanisms
(e.g. spasm of plaque-free arteries).
any Necrosis(irreversible
death) in the setting of
myocardial
ischemia(prolonged lack of
oxygen supply) should be
labelled as MI
According to ACC/AHA:According to WHO:

8. EPIDEMEOLOGY
It has been reported that the majority of deaths (39%) in low- and middle-income
countries under the age of 70 years are due to CHD. Myocardial Infarction (MI) is
one of the major complications of CHD. The Asian population is more susceptible
to MI. It has been estimated that MI is 50% higher in South Asians than in white
people in the UK.
Another study showed that the high prevalence of MI risk factors in Pakistan with
more than 30% of the population over 45 years of age is affected by this disease.
However, there is a paucity of data on the estimates of CHD risk factor burden or
of its control status in Punjab, Pakistan. Moreover, only a little information on MI
risk factors has been reported in Peshawar and Rahim yar khan, Pakistan .

10. PATHOPHYSIOLOGY

12. COMPLICATIONS

13. DIFFERENCE BETWEEN ISCHEMIA AND HYPOXIA
NOTE: Angina is due to hypoxia
MI is due to ischemia
Ischemia injures tissues faster than hypoxia

14. DIFFERENCE BETWEEN ANGINA AND MYOCARDIAL
INFARCTION
ANGINA MYOCARDIAL INFARCTION
Site: retrosternal, radiate to arm,
epigastrium, neck
As for angina
Precipitated by exercise or
emotion
Often no obvious precipitant
Relieved by rest, nitrates Not relieved by rest, nitrates
Mild/moderate severity Usually severe (may be silent)
Anxiety absent or mild Severe
No nausea or vomiting Nausea and vomiting are common
No increased sympathetic activity Increased sympathetic activity

15. DIFFERENCE BETWEEN STABLE ANGINA,UNSTABLE
ANGINA , STEMI AND NSTEMI

16. Clinical problem Pathology
Stable angina Ischemia due to fixed artheromatosus
stenosis of one or more coronary arteries
Unstable angina Ischemia caused by dynamic obstruction
of a coronary artery due to plaque rupture
with superimposed thrombosis and spasm
Myocardial Infarction Myocardial necrosis caused by acute
occlusion of coronary artery due to plaque
rupture and thrombosis
Heart failure Myocardial dysfunction due to infarction
and ischemia
Arrhythmia Altered conduction due to ischemia and
infarction
Sudden death Ventricular arrhythmia , asystole of
massive myocardial infarction

17. CLINICAL SYMPTOMS

18. DIAGNOSIS
These tests include:
Electrocardiography, Blood testing, and Echocardiography.
1. ECG changes:
 ST segment elevation, followed by T wave inversion and Q waves, are associated
with transmural infarction.
 ST segment depression and T wave inversion are associated with subendocardial
infarction

19. DIAGNOSIS
2. Blood Testing:
• Living myocardial cells contain enzymes and proteins (e.g., creatine kinase,
troponin I and T, myoglobin) associated with specialized cellular functions.
• These enzymes and proteins can be detected by a blood sample analysis.
• Serum cardiac markers:
o Creatinine phosphokinase (CK)
o Lactic dehydrogenase (LDH)
o Cardiac specific troponins (cTn)

20. DIAGNOSIS
3. Echocardiography:
• An echocardiogram may be performed to compare areas of the left ventricle that
are contracting normally with those that are not.
• The echocardiogram may be helpful in identifying which portion of the heart is
affected by an MI and which of the coronary arteries is most likely to be occluded.

21. DIAGNOSIS

22. DIAGNOSIS

23. TREATMENT ALOGARITHM

24. EMERGENCY TREATMENT

25. STEMI
Class Drug name Dose Contraindication Adverse
effects
Nitrates Nitroglycerin Sublingual:
0.4mg
IV:
5-10ug/ml
Hypotension,
Hypovolemia,
Pericarditis
Dizziness,
Postural
hypotension,
Tachycardia
Opioid
analgesic
Morphine IV bolus: 2-
4mg, every
5-10 mins
until pain
relieve
Pheochromocytom
a,
Heart failure
Hypotension,
Vomiting,
Bronchospasm,
Abdominal
pain
Fibrinolytic Enoxaprin Subcutaneo
us: 1mg/kg
Q12hrs
Uncontrolled
hypertension,
Active major
bleeding
Anemia,
Hemorrhage
Heparin IV: 60mg/kg Active major
bleeding,
Hypersensitivity
Numbness,
Headache,
Chest pain

26. NSTEMI
Class Drug name Dose Contraindications Adverse
effects
NSAIDS Aspirin Loading dose:
150-325mg
Maintenance
dose:
75-100mg
Peptic ulcer,
Bleeding disorder,
Cardiac failure
Increase
bleeding time,
GI hemorrhage

27. Class Drug name Dose Contraindications Adverse effects
Beta- blockers Bisoprolol 10mg OD Acute heart failure Depression,
muscle weakness
Beta- blockers Metoprolol IV bolus: 5 mg
at 2 minute
intervals
Oral: 50 mg Q
6 hrs,
Maintenance
dose:
100 mg BD
Cardiogenic shock,
sinus Bradycardia
Dizziness,
Depression.
Stomach pain.
Beta- blockers Carvedilol Initial dose
12.5mg OD
Maintenance
dose 25mg OD
Acute heart failure Depression,
Angina,
thrombocytopenia

28. Class Drug name Dose Contraindications Adverse
effects
Calcium-
channel
blockers
Verapamil 80-120mg
TID
Acute porphyria,
Bradycardia
Atrial fibrillation,
Heart failure,
Cardiogenic shock
Constipation,
Edema
Calcium-
channel
blockers
diltiazem 60mg TID Acute porphyria,
Bradycardia
GI disturbances
Edema,
Hypotension

29. COMORBIDITIES

30. Patients with MI and hypertension should be treated with goal to maintain Blood pressure.
Such antihypertensive drugs which reduce cardiovascular events in Myocardial infarction
patients are recommended (ACEI, ARB, β blockers and statins)
These drugs can be prescribed individually or in combination according to patient
condition.

31. Impaired cardiac function can worsen renal function, a complex interaction known as the
cardiorenal syndrome.
Such antihypertensive drugs which reduce cardiovascular events in Myocardial infarction
patients are recommended (ACEI, ARB, β blockers, diuretics, anti thrombotic and
vasodilators)
These drugs can be prescribed individually or in combination according to patient
condition.

32. It has been recognized for some time that diabetics experience a greater mortality during
the acute phase of myocardial infarction (MI) and a higher morbidity in the post
infarction period.
In patients with MI and diabetes, ACE inhibitors and β blockers should be prescribed
The prevention or retardation of nephropathy in the diabetic patient is a good example
in which ACE inhibitors act by diabetes-specific and nonspecific mechanisms.

36. NON PHARMACOLOGICAL TREATMENT
 Life style modification
Smoking cessation:
Two yrs after cessation risk of MI drops by 50%.
Vaccination:
Update vaccine due to more chances of infection
Angioplasty recommend:
In elderly patients
Physical activity and exercise:
 Exercise 30 min per day regularly
 Physical activity can help control blood cholesterol, diabetes, obesity as
well as help lower blood pressure.
 Losing even 10% from current weight can lower your heart disease risk.

37.  Diet Modification:
 Diets rich in soluble fiber, vegetables, fruits, and
whole grains, and low in saturated fat and
cholesterol should be encouraged.
 Low salt diet
 Lipid Management:
 Saturated fat (<7% of total calories).
 Cholesterol and trans fatty acids (<200mg/day).
 Plant sterols (2g/day).
 Viscous fiber (10g/day)
 Olive oil, rapeseed oil to be used instead of
saturated oil.
 Use of omega-3 fatty acids (fish).

38. PATIENT COUNCELLING
• Eat low salt diet to maintain Blood pressure
• Take low fat diet to reduce cholesterol level
• Exercise 30mins 3-4 times
• If smoker quit smoking
• Don't take certain medicines without your doctor
advise (NSAIDS, vitamins supplements)
• Update vaccination due to chances of infection
• Losing weight

39. CASE STUDY

40. CASE STATEMENT
M. Shareef is a 65 years old male patient having 76 kg weight from Abottabad on 20th
April,2017. He is a known case of diabetic patient since 12 years and Coronary artery
disease for the last 2 years. He was admitted to hospital with the chief complaints of
fever, chest pain and breathlessness for the last 6 hours. Patient had an episode of
vomiting. He was conscious and well oriented and overall health state was weak .Past
medications include Metformin 500mg TID, enalapril 20mg OD, Carvedilol 25mg OD
and atorvastatin 20mg OD. Patient was immediately admitted in ICU. Within 10 mins,
ECG was performed and based upon diagnosis Oxygen & Cardiac rhythm monitoring
was performed. Further his management includes Aspirin 300mg PO, Clopidogrel
600mg PO followed by 150mg daily for 1 week and 75mg daily thereafter,
Streptokinase 1 MIU/hr, Inj Morphine, Inj Metoclopromide I.V Stat 5mg/ml.

41. Patient name: Muhammad Shareef
Age: 65 years
Gender: Male
Date of Administration: 20th
April, 2017
Admission department: Emergency

42. Chief complaint:
Chest pain for last 6 hours
Breathlessness for last 6 hours
Fever (101 F) for last 6 hours
Episodes of vomiting
Past medical history:
Diabetes mellitus since 12 years
Coronary artery disease for last 2 years

43. Past medication history:
Metformin 500mg TID
Enalapril 20mg OD
Carvedilol 25mg OD
Atorvastatin 20mg OD
Subjective finding
Chest pain
Breathlessness
Episodes of vomiting
Fever (101 F)

44. Objective finding
ECG: ST segment elevation & Q wave development
Cardiac biomarkers: Troponin T raised, CK-MB raised
Chest X-ray: Cardiothoracic ratio increased showing LV dilatation, pulmonary edema
not evident.
Blood tests: ESR & CRP raised
Recently diagnosed for
Patient is recently diagnosed for ST segment Elevation Myocardial
infarction (STEMI)

45. VITAL SIGNS
Sign Normal 1 2 3 Comments
BP
120mmHg/
80mmHg
160/90 150/90 140/90 Raised BP
TEMP 37 C 38.3 38 38 Pyrexia
RR 12-18/min 30 29 27 Tachypnea
PR
60-100
beats/min
115
beats/min
112
beats/min
112
beats/min
Tachycardia

46. Lab Interpretation
Normal range Lab value Interpretation
Hematology Data
ESR <20mm/hr 23mm/hr Raised
CRP <10mg/dL 19mg/dL
Raised (severity of
myocardial damage)
Normal range Lab value interpretation
Cardiac Biomarkers
Troponin T 0.01ng/ml 0.05 ng/ml
Diagnosis of cardiac
injury
CK-MB 3-5% 15%
Indication of myocardial
damage

47. ECG interpretation
ST segment elevation
Q wave development
Progressive loss of R wave

48. Chest X-Ray
Cardiothoracic ratio increased showing LV dilatation, pulmonary edema not evident.

49. THERAPEUTIC PROBLEM LIST

50. HOME MEDICATION

51. MEDICATION
Brand name Generic name Formulation
Prescribed dose
(20/04/2017)
Morphine Morphine Inj 3.8mg/hr
Streptokinase Streptokinase Inj 1 MIU/hr
Metoclopramide Metoclopramide Inj 5mg/ml
Ascard Aspirin PO
300mg
Lowplat clopidogrel PO
600mg PO followed by 150mg
daily for 1 week & 75mg daily
thereafter

52. Class Brand name
Dosage regimen
prescribed
Route of
administration
Cost of
treatment
1st
line of drug for
respective disease
Antiplatelet
(Lowplat)
clopidogrel
600mg PO Rs.140/- Yes

53. Drug Caution ADRs Interactions Contraindications
Clopidogrel
Patient at risk
of increased
bleeding so
use with
caution in
surgery
patients
Bleeding
•Morphine(if orally
given) reduces the effect
of clopidogrel
•Clopidogrel with
aspirin chances of
bleeding
Hepatic & renal
Impairment,
hypersensitivity,
peptic ulcer

54. EVALUATION OF DRUG ADMINISTRATION
Prescribed time of administration Effect of Food Pharmacist Recommendation
In evening ----------
Should take regularly but if bleeding
occurs then inform doctor
Is the drug rational Is the drug cost effectiveness Any alternative drug
No, because its dose is not
according to guidelines but it is 1st
line of drug
Yes, according to patient socioeconomic
status
Cocard
Rs. /-95

55. Class Brand name
Dosage regimen
prescribed
Route of
administration
Cost of
treatment
1st
line of drug for
respective disease
Thrombolytic
agent
streptokinase
1 MIU/hr
Inj Rs.4738/- Yes

56. Drug Caution ADRs Interactions Contraindications
streptokinase
Bleeding
disorders, high
blood pressure,
endocarditis,
recent biopsy or
surgery, recent
injury,
any allergies.
Bleeding, nausea,
vomiting, fever,
Allergic reactions,
Respiratory
depression, Back
pain
The addition of aspirin
to Streptokinase(if orally
given) causes a minimal
increase in the risk of
minor bleeding but does
not appear to increase
the incidence of major
bleeding
Cardiac stroke,
trauma, bleeding
diathesis

57. EVALUATION OF DRUG ADMINISTRATION
Prescribed time of
administration
Effect of Food Pharmacist Recommendation
It administered as soon as
possible (within 6 hours after
symptoms (e.g. chest pain)
appear.
……………..
Should take regularly but if
bleeding occurs then inform
doctor
Is the drug rational Is the drug cost effectiveness Any alternative drug
No
No
Enoxaparin
(Rs:150)

58. Class Brand name
Dosage regimen
prescribed
Route of
administration
Cost of
treatment
1st
line of drug for
respective disease
Opioid
analgesic
Morphine
sulfate
1mg/1ml
2-4mg, every 5-10
mins
IV bolus Rs. /-354
Ist drug of choice for
pain associated with
myocardial infarction

59. Drug Caution ADRs Interactions Contraindications
Morphine
Cardiac
arrhythmia
Abdominal pain,
bronchospasm,
hypertension,
sedation
Morphine reduces the
effect of clopidogrel
Pheochromocytoma,
Heart failure

60. EVALUATION OF DRUG ADMINISTRATION
Prescribed time of administration Effect of Food Pharmacist Recommendation
Until pain relieve ---
Monitor patient heart rate &
respiratory rate
Is the drug rational Is the drug cost effectiveness Any alternative drug
yes
Yes, because no other cheaper alternative
is available
Morfscot 20mg /ml
Rs: /-400

61. Class Brand name
Dosage regimen
prescribed
Route of
administration
Cost of
treatment
1st
line of drug for
respective disease
Antiplatelet
Ascard
(Aspirin)
300mg loading dose PO Rs 52 Yes 1st
line

62. Drug Caution Contraindications ADRs
NSAIDS Allergic,
bronchospasm
Peptic ulcer, Bleeding
disorder, Cardiac failure
Increase bleeding time,
GI hemorrhage

63. EVALUATION OF DRUG ADMINISTRATION
Prescribed time of administration Effect of Food Pharmacist Recommendation
Every 30min ---- Monitor bleeding time
Is the drug rational Is the drug cost effectiveness Any alternative drug
Yes Yes
Loprin
(Rs 52)

64. Class
Generic
name/Brand
name
Dosage
regimen
prescribed
Route of
administration
Cost of
treatment
1st
line of drug for
respective disease
Antidopaminergic
Metoclopramide/
Maxolon
5mg/ml Inj Rs.200/- Yes

65. Drug Caution ADRs Interactions Contraindications
Metoclopramide
Caution
while driving
,handling
machinery
or other
tasks
requiring
alertness
because it
may
produce
drowsiness.
Extrapyramidial
reaction,
drowsiness,
diarrhea, rash
-------
GI obstruction,
perforation or
hemorrhage,
pheochromocytoma

66. EVALUATION OF DRUG ADMINISTRATION
Prescribed time of administration Effect of Food Pharmacist Recommendation
Stat ---------- ----------
Is the drug rational Is the drug cost effectiveness Any alternative drug
No as drug is not cost effective, although it is
1st
line of drug, and its dose is according to
guidelines .
No, as its alternative is available.
Stomac
Rs. /-87.60

67. TREATMENT OUTCOME
Chest pain will be treated by Streptokinase and Inj Morphine
Fever will be reduced by using Anti-pyretics
Breathlessness will be controlled by Oxygen
Vomiting will be treated by Metoclopromide I.V Stat

68. PATIENT EDUCATION
Exercise 30 min per day 7 day a week
Diets rich in soluble fiber, vegetables, fruits, and whole grains, and low in
saturated fat and cholesterol should be encouraged.
Check your blood glucose levels routinely
Take your all medicines regularly.
Keep appointments for regular follow-ups

69. REFERENCES
• http://www.nature.com/nrrheum/journal/v11/n12/abs/nrrheum.2015.
112.html
• http://www.medscape.org/viewarticle/497856
• http://circ.ahajournals.org/content/97/1/12
• https://www.ncbi.nlm.nih.gov/pubmed/22317927
• http://www.medscape.org/viewarticle/736181
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4583611/
• https://www.slideshare.net/adolescent4u/myocardial-infarction