Summary 8

Mr L, a 63-year-old Chinese man, under follow-up at klinik kesihatan for hypertension, dyslipidemia and ischemic heart disease on aspirin, perindopril, bisoprolol and simvastatin, presented with a sudden onset of central chest pain associated with profuse sweating and palpitations which was not relieved with 2 tablets of sublingual GTN. He had no symptoms of heart failure. Angiogram was done 3 years ago which showed 2 vessel occlusions of 65% (no formal report available).

Question: What degree of coronary artery occlusion is considered significant enough for intervention?

Stenting was unsuccessful and he was advised for CABG, but the patient refused surgical management.

Question: Broadly, what are the different types of stents used in CAD?

He has a strong family history of coronary artery disease, whereby his father died at the age of 55 years after a myocardial infarction and his 2 brothers have CAD for which CABG has been performed.

Question: When is CABG preferred instead of stenting? What is the risk of stenting?

Prior to his presentation to ED, he was seen by a general practitioner at a private clinic where he received Aspirin and 1 tab of S/L GTN.
On examination, he was alert but in pain. Patient was not in shock as apparent from warm peripheries, BP: 146/92 mmHg, Pulse: 90bpm of good volume, and RR:20 breaths/min. SpO2 was 94%. Apex beat was displaced to 1cm lateral to left mid clavicular line at 5th intercostal space indicating cardiomegaly. Other systemic examinations were unremarkable.
Upon investigation, troponin I was raised (0.13ng/mL) and ECG showed sinus rhythm with ST elevation of 0.2mV on leads V1, V4, V5 and 0.4mV on leads V2, V3 with hyperacute T wave changes. He was treated as extensive anterior wall STEMI with antiplatelets, morphine and oxygen. Streptokinase infusion of 1.5mega units in 100ml of normal saline was started with a door-to-needle time of 40 minutes.

Question: What is the window of time for thrombolytic treatment?

After a successful reperfusion as evident by reduced pain and reduced ST-elevation by 50%, he was transferred to coronary care unit. Patient remained hemodynamically stable. Blood pressure was maintained below 130/80 mmHg.

Question: What complications can occur because of streptokinase? When should streptokinase not be given?

Blood sugar and renal profile were normal. LDL was 2.7 mmol/l which is slightly higher. He was treated with double antiplatelet agents, ACE-inhibitor, beta-blocker, statin, nitrates, and s/c fondaparinux.

Question: What benefit do statins have in acute MI? Does fondaparinux have any advantages over enoxaparin?

Patient was advised by the treating physicians as well as a dietician for lifestyle modification. Cardiac enzymes peaked within 24 hrs and showed a reducing in trend thereafter. An echocardiogram was done within 48 hrs which showed reduced LVEF (30-35%) and extensive wall motion abnormalities. He was discharged on second day of admission with T.Bisoprolol 1.25mg OD, T.Perindopril 2mg OD, T.Aspirin 150mg OD, T.Clopidogrel 75mg OD, T.Atorvastatin 40mg ON, T.Isosorbide mononitrate 30mg OD and S/L GTN 0.5mg PRN. An appointment for cardiac clinic at Johor Baru hospital was given for 15/1/2018.

Question: What is the benefit of perindopril in this patient who is not in heart failure?

Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-ShareAlike 3.0 License