Case No. 23

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Case No. 23

• Lin, I-Chen(Tina)

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• A 30 y/o female, frail looking, pale came in
  stretcher borne with chief complaint of weakness
  and vomiting. An hour PTC (prior to
  consultation), she was noticed to be
  uncomfortable with cold clammy perspiration
  immediately after breakfast.
• BP-80/60, RR-24/m
• Diabetic for 5 years, on insulin 20uNPH at
  6am, 15uNPH at 6pm
• ECG showed ST elevation anteroseptal and lateral
  areas.

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Diagnosis Acute Myocardial infarction
Hypoglycemia

• ID Acute myocardial infarction (MI) is defined
  as death or necrosis of myocardial cells. MI
  means that part of the heart muscle suddenly
  loses it's blood supply.
• This accelerated form of atherosclerosis occurs
  regardless of whether a patient has
  insulin-dependent or noninsulin-dependent
  diabetes.
• The proportion of painless AMI is great in
  patient with diabetes mellitus and it increase
  with age.
• May present as sudden-onset breathlessness which
  may progress to pulmonary edema.

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Signs and Symptoms

• Chest pain described as a pressure sensation,
  fullness, or squeezing in the midportion of the
  thorax
• Radiation of chest pain into the jaw/teeth,
  shoulder, arm, and/or back
• Associated dyspnea or shortness of breath
• Associated epigastric discomfort with or without
  nausea and vomiting
• Associated diaphoresis or sweating
• Syncope or near-syncope without other cause
• Impairment of cognitive function without other
  cause

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Laboratory examination

• 1.Electrocadiogram(ECG) The first test is the
  ECG, which may demonstrate that a MI is in
  progress or has already occurred
• 2.Blood Tests Blood tests can be performed to
  detect evidence of myocardial cell death.
• a.creatine phosphokinase (CK)
• b.MB isoenzyme of CK (CKMB)
• c.cardiac-specific troponin T (cTnT)
• d.cardiac-specific troponin I (cTnI)
• 3.Echocardiography
• The echocardiogram can be helpful in identifying
  which portion of the heart is affected by a MI,
  and which of the coronary arteries is most likely
  to be occluded.

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Normal Values of Blood Tests toDetect Myocardial Infarction Normal Values of Blood Tests toDetect Myocardial Infarction

Analysis Normal Range
Total creatinine phosphokinase (CK) 30-200 U/L
CK, MB fraction 0.0-8.8 ng/mL
CK, MB fraction percent of total CK 0-4
CK, MB2 fraction lt 1 U/L
Troponin I 0.0-0.4 ng/mL
Troponin T 0.0-0.1 ng/mL
     
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Management

• pharmacologic regimen
• 1.antithrombotic agents
• 2.beta-adrenoceptor blockers
• 3.angiotension-converting enzyme inhibitor (ACEI)
• 4.other agent Nitrates

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1.antithrombotic agents

• Platelet inhibitor Aspirin
• MOA inhibits synthesis of thromboxane A2
• Anticoagulant Heparin
• MOA inhibitor antithrombin III
• Fibrinolytics tPA
• MOA lyze thrombus by formation of serine
  proteose plasmin
• Glycoprotein IIb/IIIa Antagonists Abviximab
• MOA inhibit of fibrinogen
• Adverse effect bleeding, GIT symptom

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2.beta-adrenoceptor blockers

• Ex Metoprolol, Atenolol, Esmolol
• MOA inhibit Beta-1 receptor
• adverse effect bradycardia, hypotension

3.angiotension-converting enzyme inhibitor (ACEI)

• ACEI Captopril, Enalapril
• MOA inhibit angiotension-converting enzyme
• adverse effect Dry cough

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4.other agent Nitrates

• Ex Nitroglycerine
• route Sublingual tablet, Spray, Transdermal or
  paste, Intravenous
• MOA releases Nitric Oxide??cGMP?relaxation
• adverse effect throbbing headache, flushing of
  the face, dizziness, postural hypotension

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• 5) Tx hypoglycemia

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non-pharmacologic regimen 1.Supplemental
Oxygen Supplemental oxygen should be
administered to patients with symptoms and/or
signs of pulmonary edema or pulse oximetry
reading less than 90 blood oxygen
saturation. 2.Control blood pressure 3.Eat a low
fat diet 4.more fruit and vegetable
diet 5.Control DM 6.Exercise daily to improve
heart fitness.
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thank you