Ppt

1. BY-WUBET M.(MEDICAL INTER)
MODERATOR-Dr. HASSEN (INTERNIST)
Dr. REDIET(MD)
ACUTE CORONARY
SYNDROME MANAGEMENT

2. OUTLINES
6/2/2023
WUBET, ACS,
 Case presentation
 Introduction
 Clinical presentation
 Diagnosis
 Management
 Complications
 Case management strength and pitfalls
2

3. CASE PRESENTATION
6/2/2023
WUBET, ACS,
 D.M an 81 years old male pt from Assela admitted
on 27122008 and discharged on 01/01/2009
Eth.c
CC-Exacerbation of chest pain /5hrs
duration
Presented with a left side of squeezing
type of chest pain which radiates to his left
shoulder & left arm. The pain begins while
he was sitting and it is very severe, during
the episode he experienced nausea,
3

4. CASE PRESENTATION
6/2/2023
WUBET, ACS,
 No aggravating or relieving factor
 He had the same attack a week back
 Otherwise no hx of cough, orthopenia ,
PND or body sweeling
 Has no hx of fever or headache
 No hx of intermittent claudication
 No hx of smoking
 No hx of known DM, HTN or cardiac illness
4

5. PHYSICAL EXAMINATION
6/2/2023
WUBET, ACS,
 GA-ASL
 VS-BP-11080mmhg PR-80(RR)
RR-28 Temp. 36.5 OC
 HEENT-Pink conjunctiva & NIS
-Wet tongue & buccal mucosa
 LGS-No LAP
 Chest-no SC & IC retraction
resonant, clear with good air entry
5

6. PHYSICAL EXAMINATION
6/2/2023
WUBET, ACS,
 CVS-all accessible arteries are palpable
with full volume
 JVP not raised
 Quiet pericordium
 Apical impulse at 5th ICS lateral to MCL
 No heave or thrill
 S1 & S2 well heard
 No murmur or gallop
6

7. PHYSICAL EXAMINATION
6/2/2023
WUBET, ACS,
 Abdomen-flat which moves with respiration
soft & non tender
 no mass or organomegally
 GUS-no CVAT
 MSS-no edema
 INTG-no pallor
 CNS-concsious & well oriented
GCS-1515
7

8. Asst- Acute coronary syndrome
6/2/2023
WUBET, ACS,
PLAN
 Do cardiac troponin, RFT, serum
electrolyte, echo, coagulation profile
 Put in INo2
 Strict bed rest
 ASA 325mg po loading then 81mg po/day
 Clopidogrel 300mg po loading then 75mg
po/day
 Atrovastatine 80mg po/day
8

9. PLAN…
6/2/2023
WUBET, ACS,
 Atenolol 25mg po/day
 Enalapril 5mg po/day
 Bisacodyl 5mg po/day
 Heparin 4000IU IV loading then 12,500IU
SC BID
 Tramadol 50mg IV TID
 Cemitidine 200 mg IV bid
 Followed with cardiac follow chart
9

10. INVESTIGATSIONS
6/2/2023
WUBET, ACS,
 CBC
 WBC-7300
 N-61.6%
 L-28.8%
 RBC-45600
 HGB-14.3gdl
 HCT-44.1%
 PLT-42300
 RBS-140g/dl
 Serum electrolytes
 K-6.69mmol/l
 Na -146.2mmol/l
 Cl -110.9mmol/l
 Cardiac troponin(TNIU)
 5.49g/l
 Coagulation profile
 PT-16.2 Sec
 PTT-34.8 Sec
 INR-1.39
 Lipide profile
 Tc-197mg/dl
 TG-140mg/dl
 HDL-51mg/dl
 LDL-118mg/dl
 RFT
 UREA-46mg/dl
 Cr.-1.25mg/dl
10

11. ECG
6/2/2023
WUBET, ACS,
 ST segment elevation
from V1-V5
 Poor T wave
progression V1&V4
11

12. After IX……Asst-STEMI+
Hyperkalemia
6/2/2023
WUBET, ACS,
 Hyperkalemia managed by regular insulin
10IU IV Stat and giving 3 vials of 40%
dextrose iv push then D10% with 40
dropes for 4 hours
 lasix 20mg IV stat
 After management….K-4.99mmol/L
12

13. PROGRESS NOTE
6/2/2023
WUBET, ACS,
 P: On his 3rd DOA for the dx of STEMI
 Done: All above management plans
 Subj: The chest pain is decreasing in
intensity
 Obj: V/S: BP=80/50, PR=48, RR=26,
T=36.2C
 Each system finding =The same
 Asst: The same + hypotension
 Plan: Hold Atenolol & Enalapril
Challenge with 300ml of NS
13

14. Progress note
6/2/2023
WUBET, ACS,
14
 P: On his 5th DOA for the dx of STEMI
 Done: All above management plans
 Subj: no chest pain
 Obj: GA =Well Looking
 V/S: BP=90/70, PR=72, RR=24,
T=35.9C
 Each system finding =The same
 Asst: The same
 Plan: Do RFT, ECG
Continue the other mgt

15. Discharge Summary
6/2/2023
WUBET, ACS,
15
 S: NO Complaint
 Obj: BP =10070 PR=68 RR=24 T =36.7C
Plan: -ASA 81mg po/day
Atrovastatin 40mg po/day
Enalapril 2.5mg po/day
Clopidogrel 75mg po/day
Bisacondyl 5 mg po/day
Warfarin 5mg po/day
Appointed after 1week(addition of
Metoprolol, adjustment of Enalapril)

16. INTRODACTION
6/2/2023
WUBET, ACS,
 IHD is a condition in which there is an
inadequate supply of bd & O2 to the
portion of myocardium
 Spectrum of presentasion
1. Asymptomatic
2. Sudden cardiac death
3. Ischemic CMP
4. Stable angina
5. Acute coronary syndrome
A. Unstable angina
B. NSTEMI
16

17. EPIDIMOLOGY
6/2/2023
WUBET, ACS,
 More than 1.4 million individuals in the US are
hospitalized annually with ACS, of whom
approximately two thirds have NSTE-ACS. More
 than half of those with NSTE-ACS are older than 65
years, and almost half
 are women. NSTE-ACS is more common in
individuals with one or more
 risk factors for atherosclerosis (Chapter 51),
peripheral vascular disease, or a
 chronic inflammatory disorder, such as rheumatoid
arthritis, psoriasis, or
 infection
17

18. ACUTE CORONARY
SYNDROME
6/2/2023
WUBET, ACS,
 Unstable angina -Symptoms of MI but no
elevation in cardiac enzymes and +-
ECG changes
 NSTEMI – No ST elevation on ECG ,
elevated cardiac enzymes and
symptoms of MI
 STEMI – Significant ST elevation or new
LBBB on ECG, elevated cardiac
enzymes, symptoms of MI
18

19. 6/2/2023
WUBET, ACS,
19

20. UNSTABLE ANGINA AND
NSTEMI
6/2/2023
WUBET, ACS,
PATHOPHSIOLOGY
 NSTE-ACS is most commonly caused by
an imbalance b/n O2 supply and O2
demand resulting from a partially
occluding thrombus forming on a
disrupted atherothrombotic coronary
plaque or on eroded coronary artery
endothelium
20

21. PATHOPHYSIOLOGY…
6/2/2023
WUBET, ACS,
 Dynamic obstruction (e.g. coronary
spasm, as in PVA)
 Severe mechanical obstruction due to
progressive coronary atherosclerosis;
and
 Increased myocardial oxygen demand
produced by conditions such as fever,
tachycardia, and thyrotoxicosis in the
presence of fixed epicardial coronary
obstruction
21

22. CLINICAL PRESENTATION
6/2/2023
WUBET, ACS,
 Chest pain,
Often severe enough to be described as
frank pain
Typically located in the substernal region
or sometimes in the epigastrium
Radiates to the left arm, left shoulder,
and/or neck
22

23. CLINICAL PRESENTATION
6/2/2023
WUBET, ACS,
 Chest discomfort; at least one of three
features:
1. It occurs at rest (or with minimal
exertion), lasting >10 minutes;
2. It is of relatively recent onset (i.e.,with
in the prior 2wks); and/or
3. It occurs with a crescendo pattern
23

24. CLINICAL PRESENTATION
6/2/2023
WUBET, ACS,
 Anginal "equivalents“-more in elderly,
females and diabetic
dyspnea
epigastric discomfort
nausea
fatigue, and faintness
24

25. PHYSICAL FINDING
6/2/2023
WUBET, ACS,
 If a large area of MI or a large NSTEMI,
Diaphoresis
Pale, cool skin
Sinus tachycardia
A third and/or fourth heart sound
Basilar rales; and
Sometimes, hypotension
25

26. DIAGNOSTIC EVALUATION
6/2/2023
WUBET, ACS,
 3 major noninvasive tools are used in the
evaluation of NSTEMI-ACS:
1. The ECG
2. Cardiac biomarkers
3. Stress testing
26

27. ELECTROCARDIOGRAM
6/2/2023
WUBET, ACS,
 ST-segment depression occurs in 30-
50% of patients
 T -wave changes are common but are
less specific signs of ischemia, unless
they are new and deep T-wave inversions (
>0.3 Mv)
27

28. CARDIAC BIOMARKERS
6/2/2023
WUBET, ACS,
 NSTEMI pt have elevated biomarkers of
necrosis, such as cardiac troponin I or T,
which are specific, sensitive, and the
preferred markers of myocardial necrosis
 Distinguish patients with NSTEMI from
those with UA
28

29. ST-Segment Elevation MI
6/2/2023
WUBET, ACS,
PATHOPHYSIOLOGY
 Usually occurs when coronary blood
flow decreases abruptly after a
thrombotic occlusion of a coronary
artery previously affected by
atherosclerosis
29

30. PATHOPHYSIOLOGY
6/2/2023
WUBET, ACS,
 Amount of myocardial damage caused
depends on:
1. The territory
2. Whether or not the vessel totally
occluded
3. The duration
4. The quantity of blood supplied by
collateral vessels
5. The demand for oxygen of the
myocardium
30

31. CLINICAL PRESENTATION
6/2/2023
WUBET, ACS,
 Precipitating factors before STEMI, such
as:
vigorous physical exercise
emotional stress, or
a medical or surgical illness
 Pain is the most common presenting
complaint
Deep and visceral
Heavy, Squeezing, and crushing
Occasionally, it is described as stabbing
31

32. DDX
6/2/2023
WUBET, ACS,
 Acute pericarditis
 Pulmonary embolism
 Acute aortic dissection
 Costochondritis, and
 Gastrointestinal disorders
32

33. CLINICAL PRESENTASIONS
6/2/2023
WUBET, ACS,
 Pallor, perspiration & coolness of the
extremities
 Substernal chest pain persisting for
>30min
 Precordium is usually quiet, & AI d/t to
palpate
 Ventricular dysfunction:
4th and 3rd heart sounds
decreased intensity of the 1st HS, and
paradoxical splitting of the 2nd HS
33

34. LABORATORY FINDING
6/2/2023
WUBET, ACS,
 STEMI progresses through the ff
temporal stages:
Acute (first few hours-7 days)
Healing (7-28 days), and
Healed (>29days)
34

35. LABORATORY FINDING
6/2/2023
WUBET, ACS,
 The laboratory tests of value in
confirming the diagnosis may be
divided into 4 groups:
ECG
Serum cardiac biomarkers
Cardiac imaging, and
Nonspecific indices of tissue necrosis
and inflammation
35

36. ECG
6/2/2023
WUBET, ACS,
 During the initial stage, total occlusion of
an ECA produces ST-segment elevation
 A minority of patients who present
initially without ST-segment elevation
may develop a Q-wave MI
36

37. ECG
6/2/2023
WUBET, ACS,
 Anterior wall ischemia – 2 or more of
precordial leads (V1-V6)
 Anteroseptal ischemia – Leads V1 to V3
 Apical or lateral ischemia – Leads aVL and
I, & leads V4 to V6
 Inferior wall ischemia – Leads II, III, and
aVF
 Right ventricular ischemia – Right-sided
precordial leads
 Posterior wall ischemia – Posterior
37

38. 6/2/2023
WUBET, ACS,
ISCHEMIA LEADS ARTEARY
Anterior wall 2 or more of
precordial leads
(V1-V6)
Anteroseptal Leads V1 to V3
Apical or lateral aVL and I & leads
V4 to V6
Inferior wall II, III, and aVF
Right ventricular Right-sided
precordial
Posterior wall Posterior
precordial
38

39. CARDIAC TROPONIN
6/2/2023
WUBET, ACS,
 The criteria for AMI require a rise and/or
fall in cardiac biomarker values with at
least one value above the 99th percentile
of the upper reference limit for normal
individuals
39

40. Cardiac-specific Troponin
6/2/2023
WUBET, ACS,
 cTnT and cTnI have amino-acid
sequences different from those of the
skeletal muscle forms of these proteins
 Not normally detectable in the blood of
healthy individuals
 Levels of cTnl and cTnT may remain
elevated for 7- 10 days after STEMI
40

41. Creatine Phosphokinase
6/2/2023
WUBET, ACS,
 Rises within 4-8h & returns to normal by
48-72 hr
 It has lack of specificity for STEMI
 The MB isoenzyme of CK has the
advantage over total CK that it is not
present in significant concentrations in
extracardiac tissue and therefore is
considerably more specific
41

42. CARDIAC IMAGING
6/2/2023
WUBET, ACS,
Echocardiography
Abnormalities of wall motion
As a screening tool in the Emergency
Detection of reduced function of LV
serves as an indication for therapy with
ACEI
Doppler echo is useful in the detection
of a VSD and MR
Radionuclide Imaging Techniques
Cardiac MR
42

43. MANAGEMENT

44. PREHOSPITAL CARE
44
1. Recognition of symptoms by the pt &
prompt seeking of medical attention
2. Rapid deployment of an emergency
medical team capable of performing
resuscitative maneuvers
3. Expeditious transportation of the patient to
a hospital facility that is continuously
staffed by physicians & nurses skilled in
managing arrhythmias & providing
advanced cardiac life support
4. Expeditious implementation of reperfusion
6/2/2023
WUBET, ACS,

45. EMERGENCY DEPARTMENT
45
 Aspirin is essential in the mgt of patients
with suspected STEMI & is effective
across the entire spectrum of ACS
 When hypoxemia is present, O2 should
be administered by nasal prongs or face
mask (2-4 L/min) for the first 6-12 h after
infarction; the patient should then be
reassessed to determine if there is a
continued need for such treatment
6/2/2023
WUBET, ACS,

46. CONTROL OF DISCOMFORT
46
 Sublingual Nitroglycerin
Up to three doses of 0.4mg at about 5-min
intervals
Capable of both decreasing myocardial O2
demand & increasing myocardial O2 supply
 Contraindication
SBP <90 mmHg
Clinical suspicion of RV infarction (inferior
infarction on ECG, elevated JVP, clear
lungs, & hypotension)
6/2/2023
WUBET, ACS,

47. CONTROL OF DISCOMFORT
47
 Morphine
Is a very effective analgesic for the pain
Morphine is routinely administered by
repetitive (every 5min) IV injection of small
doses (2-4 mg)
6/2/2023
WUBET, ACS,

48. CONTROL OF DISCOMFORT
48
IV beta blockers
Control pain effectively in some patients,
presumably by diminishing myocardial O2
demand and hence ischemia
Oral beta blocker therapy should be
initiated in the first 24h
6/2/2023
WUBET, ACS,

49. CONTRAINDICATIONS OF B
ABSOLUTE RELATIVE
6/2/2023
WUBET, ACS,
49
 Signs of heart
failure
 Evidence of a
low-output state
 Increased risk for
cardiogenic shock
 PR interval >0.24
sec
 2nd or 3rd degree
heart block
 Active asthma, or
 Reactive airway
disease

50. CONTROL OF DISCOMFORT…
50
 Metoprolol 5mg Q 2-5min for a total of 3
doses, if
HR >60 beats/min
SBP > 100 mmHg
PR interval <0.24s, and
Rales, no higher than 10 cm up from the
diaphragm
 15min after the last IV dose, an oral regimen
is initiated of 50mg Q 6h for 48h, followed
by 100mg every 12h
6/2/2023
WUBET, ACS,

51. FIBRINOLYSIS
51
 If no contraindications are present
fibrinolytic therapy should ideally be initiated
within 30min of presentation
 Relative contraindications:
Current use of anticoagulants(INR >2 )
A recent (<2 wks) invasive or surgical
procedure or prolonged (>10min)
cardiopulmonary resuscitation, known
bleeding diathesis
6/2/2023
WUBET, ACS,

52. FIBRINOLYSIS
6/2/2023
WUBET, ACS,
 Pregnancy
 A hemorrhagic ophthalmic condition
(e.g., hemorrhagic diabetic retinopathy)
 Active PUD
 History of severe hypertension that is
currently adequately controlled.
52

53. HOSPITAL PHASE
MANAGEMENT
6/2/2023
WUBET, ACS,
Activity
 Kept at bed rest for first 6-12h
 By the 2nd or 3rd day, pts typically are
ambulating in their room
 By day 3 after infarction, pts should be
increasing their ambulation progressively
to a goal of 185m (600 ft) at least three
times a day
53

54. DIET
6/2/2023
WUBET, ACS,
 Because of the risk of emesis and aspiration
, pts should receive either nothing or only
clear liquids by mouth for the first 4-12h
 < 30% of total calories as fat and a cholesterol
content of 300mg/d
 Complex carbohydrates should make up 50-
55% of total calories
 Frequent & small, & enriched with foods that
are high in K, Mg & fiber, but low in sodium.
 If DM and hypertriglyceridemia, restriction of
concentrated sweets
54

55. Bowel Management
55
 Bed rest and the effect of the narcotics
used for the relief of pain often lead to
constipation
 A bedside commode rather than a bedpan,
a diet rich in bulk, and the routine use of a
stool softener such as dioctyl sodium
sulfosuccinate (200 mg/d) are recom-
mended
 If the patient remains constipated despite
these measures, a laxative can be 6/2/2023
WUBET, ACS,

56. SEDATION
56
 To withstand the period of enforced
inactivity with tranquility
 Attention to this problem is especially
important during the first few days
Diazepam5 mg
Oxazepam15-30 mg or
Lorazepam0.5-2 mg given three to four
times daily
6/2/2023
WUBET, ACS,

57. PHARMACOTHERAPY
6/2/2023
WUBET, ACS,
ANTITHROMBOTIC AGENTS
 Antiplatelet and anticoagulant therapy
 Primary goal
To maintain patency of the infarct related
artery
Reperfusion strategies
 Secondary goal
To reduce the patient's tendency to
thrombosis
57

58. Antiplatelet Drugs
58
Aspirin
 Initial treatment
 Platelet cyclooxygenase inhibitor
 Initial dose is 325 mg/d, 75-100 mg/d
thereafter
 Contraindications are:
active bleeding
aspirin intolerance
6/2/2023
WUBET, ACS,

59. Antiplatelet Drugs
59
Thienopyridine clopidogrel
 Causes irreversible blockade of the platelet
P2Y12 recp
 When added to aspirin, dual antiplatelet
therapy, shown a 20% relative reduction in:
cardiovascular death
MI or stroke
 Compared to aspirin alone but to be
associated with a moderate (absolute 1%)6/2/2023
WUBET, ACS,

60. Antiplatelet Drugs
60
Glycoprotein Ilb/ IIla inhibitors
 IV P2Y12 receptor blockers
 The addition of these agents to aspirin & a
P2Y12 inhibitor should be reserved for
unstable pts with
recurrent rest pain
elevated cTn, and ECG changes
those who have a coronary thrombus
evident on angiography when they 6/2/2023
WUBET, ACS,

61. Anticoagulants
61
 Four options,
1. UFH, long the mainstay of therapy
2. LMWH, enoxaparin, superior to UFH
in reducing recurrent cardiac events,
but increase in bleeding
3. Bivalirudin, a direct thrombin inhibitor
that is similar in efficacy
4. Fondaparinux, the indirect factor Xa
inhibitor
6/2/2023
WUBET, ACS,

62. Antithrombotic
62
 Therefore, attention must be directed to
the doses of antithrombotic agents,
accounting for:
Body weight
Cr clearance
A previous history of excessive
bleeding, as a means of reducing the
risk of bleeding
6/2/2023
WUBET, ACS,

63. ANTITHROMBOTIC AGENTS
6/2/2023
WUBET, ACS,
 Patients at increased risk of systemic or
PTE:
 with an anterior location of the infarction
 Severe LV dysfunction & HF
 A history of embolism
 two-dimensional echo evidence of mural
thrombus
 AF
 Such individuals should receive full
therapeutic levels of anticoagulant therapy
while hospitalized, followed by at least 3
63

64. Beta Adrenergic Blockers
64
 Started by IV route in pts with severe
ischemia, but this is contraindicated in the
presence of HF
 Ordinarily, oral beta blockade targeted to a
HR of 50-60beats/min
 HR-slowing CCBs, e.g., verapamil or
diltiazem, are recommended
6/2/2023
WUBET, ACS,

65. Benefits of beta blockers
65
Acute intravenous beta blockade:
Improves myocardial O2 supply demand
r/ship
Decreases pain
Reduces infarct size
Decreases the incidence of serious
ventricular arrhythmias
 In patients who undergo fibrinolysis soon
after the onset of chest pain, recurrent
ischemia and reinfarction are reduced 6/2/2023
WUBET, ACS,

66. INHIBITION OF THE RAAS
6/2/2023
WUBET, ACS,
 ACEI reduce the mortality rate after
STEMI
 The maximum benefit seen in high-risk
patients
elderly
anterior infarction
a prior infarction
globally depressed LV function
 The mechanism involves a reduction in
ventricular remodeling after infarction
66

67. INHIBITION OF THE RAAS
6/2/2023
WUBET, ACS,
 Before hospital discharge, assess LV
function with an imaging study
 ACE inhibitors should be continued
indefinitely
Clinical evident of CHF
Imaging study shows a reduction in
global LV function or a large regional
wall motion abnormality
In those who are hypertensive
67

68. OTHER AGENTS
68
 The benefits of routine use of IV
nitroglycerin are less in the
contemporary era where beta-
adrenoceptor blockers and ACE
inhibitors are routinely prescribed for
patients with STEMI
 The routine use of calcium antagonists
cannot be recommended
6/2/2023
WUBET, ACS,

69. INVASIVE STRATEGY
69
 Multiple clinical trials have demonstrated
the benefit of an early invasive strategy in
high-risk patients, i .e:
patients with multiple clinical risk factors
ST-segment deviation, and/or
positive biomarkers
6/2/2023
WUBET, ACS,

70. INVASIVE STRATEGY
70
 In this strategy, following treatment with
anti ischemic and antithrombotic
agents, coronary arteriography is carried
out within 48h of presentation,
 Followed by coronary revascularization
(PCI or coronary artery bypass
grafting), depending on the coronary
anatomy.
6/2/2023
WUBET, ACS,

71. 6/2/2023
WUBET, ACS,
71

72. Complications
6/2/2023
WUBET, ACS,
 Electrical complications (arrhythmias)
And
 Mechanical complications ("pump
failure")
72

73. COMPLlCATIONS
6/2/2023
WUBET, ACS,
1.VENTRICULAR DYSFUNCTION
 Soon after STEMI, the LV begins to
dilate
 In patients with an EF <40%, regardless
of whether or not HF is present, ACE
inhibitors or ARBs should be prescribed
73

74. COMPLlCATIONS ….
6/2/2023
WUBET, ACS,
2. Pump failure
 Killip divides patients into 4 groups:
I. No signs of pulmonary or venous congestion
II. Moderate HF
III. Severe HF, pulmonary edema; and
IV. Shock, SBP <90 mmHg & evidence of
peripheral vasoconstriction, peripheral
cyanosis, mental confusion,& oliguria
 Infarction of >40% of the left ventricle results
in cardiogenic shock
74

75. Complication..
75
3. HYPOVOLEMIA
 It may be secondary to:
 previous diuretic use
 reduced fluid intake during the early stages of
the illness,
 vomiting associated with pain or medications
 Cautious fluid administration during careful
monitoring of oxygenation and cardiac
output
6/2/2023
WUBET, ACS,

76. LONG-TERM MANAGEMENT
76
 Risk-factor modification is key,
Smoking cessation，
Achieving optimal weight，
Daily exercise，
Blood -pressure control，
Appropriate diet，
control of hyperglycemia (in diabetic
patients)
lipid management 6/2/2023
WUBET, ACS,

77. SECONDARY PREVENTION
77
 Antiplatelet agent associated with a 25%
reduction in the risk of recurrent infarction,
stroke, or cardiovascular mortality
 ACEI or ARBs and, aldosterone antagonists
should be used by patients with clinically
evident HF, a moderate decrease in global
ejection fraction, or a large regional wall motion
abnormality to prevent late ventricular
remodeling and recurrent ischemic events
 The chronic routine use of oral beta-
adrenoceptor blockers for at least 2 years
after STEMI 6/2/2023
WUBET, ACS,

78. CASE MANAGEMENT
STRENGTH PITFALLS
6/2/2023
WUBET, ACS,
 Mgt is started
early & all
inclusive
 Investigated well
 Discharge
summery written
in detail with
short appointment
 Serial ECG not
done
 Echo not done
 Vital sign not
attached to the
chart
78

79. REFERENCES
6/2/2023
WUBET, ACS,
 HARRISON PRINCIPLES OF
INTERNAL MEDICINE ( 19th ed )
 UPTODATE 21.2
79