A patient with chest pain

Source: Addy Ang, 2018

Part 1

Mr NBA, a 39-year-old Malay gentleman, a smoker, with underlying diabetes mellitus since 2011, presented with acute onset of retrosternal chest pain. The pain was suggestive of an acute coronary syndrome as it was associated with profuse sweating and palpitations. It was also crushing in nature and was radiating to his left arm.
1. What predisposes this young man to be at risk for coronary artery disease?

Since being diagnosed with diabetes mellitus in 2011, Mr NBA has not been on regular follow ups and he was also not compliant to his diabetic medication because he was asymptomatic.
2. Can diabetes be asymptomatic? Give examples of how untreated diabetes can be symptomatic

Upon physical examination, he had a blood pressure of 148/92mmHg and a pulse rate of 102 beats per minute which was regular in rhythm.
3. Does the blood pressure value imply that he has undiagnosed hypertension?

There were no signs of cardiac failure.
4. In this patient who appears to have an acute coronary event, what symptom will suggest left heart failure? What physical sign or signs will suggest left heart failure?

His ECG on presentation revealed ST elevation that was highest in the anteroseptal leads V1, V2, V3 and V4. Subtle ST elevation in the lateral leads I, aVL and V5 and reciprocal ST depression in the inferior leads III and aVF can also be seen.
5. What is the significance of “reciprocal ST depression” in the ECG of this patient?

His cardiac enzymes were also elevated.
6. Raised cardiac enzymes in the blood normally signify myocardial infarction. In what situation can one expect raised cardiac enzymes without myocardial infarction?

A random blood sugar which was done on admission showed a reading of 24mmol/L indicating that his diabetic control prior to admission was poor.
7. What will you prescribe to reduce the elevated blood sugar in this patient with a myocardial infarction?

Lipid profile which was subsequently done showed high LDL-cholesterol and total cholesterol level which suggests that Mr NBA has dyslipidemia as well.
8. What other abnormalities can you expect in the lipid profile of this patient who has poorly controlled diabetes?

Echocardiogram revealed a reduced ejection fraction of 40 – 45% which may be due to the recent myocardial infarction. There was also apical hypokinesia which implied that that region of the wall was infarcted.
9. Is it possible to have another explanation for the slightly reduced left ventricular ejection fraction?

He was then diagnosed with acute extensive anterolateral myocardial infarction with diabetes mellitus and dyslipidemia. This diagnosis was done based on the history, the ECG findings, the elevated cardiac enzymes, the high random blood sugar and the elevated LDL-cholesterol levels. He was treated with sublingual GTN and intravenous morphine 2.5mg for pain relief.
10. What is your opinion about the dose of morphine given to him?

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Part 2

Tablet aspirin 300mg and tablet clopidogrel 300mg was given as antiplatelets while intravenous metoclopramide 10mg was given as an antiemetic to prevent opioid induced vomiting.
11. What is the evidence on which dual antiplatelet therapy is now routinely given for patients with acute coronary syndromes?

He was also given intravenous ranitidine 50mg as a prophylaxis against stress ulcer. He was then started on intravenous streptokinase 1.5 mega units in 100ml normal saline over 1 hour as a thrombolytic therapy.
12. Why is thrombolytic therapy given only for patients with STEMI and not for patients with NSTEMI?

Once reperfusion therapy was successful and he remained stable, Mr NBA was transferred to the medical ward.
13. How do you recognize that thrombolytic therapy was successful?

He was then started on subcutaneous fondaparinux 2.5mg as an anticoagulant and tablet atorvastatin 40mg as it is beneficial in an acute myocardial infarction.
14. What is the rationale behind giving fondaparinux after thrombolysis? What benefit does atorvastatin provide in the acute phase in this patient?

He was also prescribed tablet bisoprolol 1.25mg as a beta blocker for its anti-ischemic, antiarrhythmic and antihypertensive effects, tablet perindopril 2mg as an ACE inhibitor as it has influence on ventricular remodeling as well as preventing infarct expansion. Tablet isosorbide mononitrate was also added as a vasodilator to reduce myocardial oxygen demand. For his diabetes, he was started on the basal bolus regimen with subcutaneous actrapid 10 units and subcutaneous insulatard 14 units. He remained in the hospital for 3 days. On the 3rd day of admission, Mr NBA was well. His blood glucose at 6.30am was 12mmol/L.
15. Assuming that he was on actrapid insulin 10 units thrice daily and insulatard insulin 14 units at night, what will you advice now based on his given morning value of blood glucose?

His subcutaneous fondaparinux 2.5mg was discontinued. Before being discharged, he was seen by the physiotherapist for cardiac rehabilitation.
16. What benefit do you expect this patient to have in a cardiac rehabilitation program?

He was then allowed to be discharged with aspirin, clopidogrel, isosorbide mononitrate, GTN, bisoprolol, perindopril, atorvastatin, ranitidine, metformin and gliclazide. He was discharged with metformin and gliclazide for his diabetes because he refused to take insulin.
17. When will you initiate insulin in a patient with Type 2 diabetes?

The dose of his oral hypoglycemic agents will be adjusted after 1 week in Klinik Kesihatan Yong Peng.
18. Assume that the patient is on Tab Metformin 1 gram twice daily and Tab Gliclazide 80mg twice daily. What advice will you give him after one week if his fasting plasma glucose is still 12mmol/L?

Since Mr NBA is a smoker, he was given a referral to the smoking cessation clinic. He was also given an appointment at this hospital’s medical outpatient department in 2 months. A renal profile and a liver function test was to be repeated in 2 weeks. Perindopril will be withheld if creatinine increases by 30% from his baseline while simvastatin will be withheld if ALT increases by 3 times its upper limit.
19. Why is it permissible to allow a rise in serum creatinine up to 30% from baseline in patients prescribed ACE inhibitors?

He was also planned to be referred to a cardiologist in Institut Jantung Negara for an angiogram.
20. Should all patients be referred for angiogram after STEMI? After NSTEMI? After UA?

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