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Acute Coronary Syndrome
MED II 2013
Case Discussion
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ACS case discussionObjectives
Understand difference of mechanisms andoutcomes of myocardial ischemia @ special clinical
scenarios
Underscore co-existence of multiple vascular bedinvolvement by athero-thrombosis
Recite the basic patho-biologic elements &
expression spectrum of Acute coronary syndromeExplore bench-bedside implementation of
diagnostic and therapeutic strategies in ACS.
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Case Discussion
Clinical History
50 yr old male, chronic heavy smoker.
History of labile hypertension.
Leads sedentary life style
Has family history of CHD (father had Myocardialinfarction at age 56)
He has been asymptomatic except for Brief and mild
chest pain , during brisk walk one day before
Presented to Emergency department withAcute and
severe chest pain lasting 10 min
EKG: ST elevation, normalized after 10 minutes
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Case Discussion
Patient gives history of Negative routine Myocardial
Perfusion Imaging (Thallium) stress test 3 months ago.
At that time, he had negative physical examination
except for a soft femoral artery bruit and BP 130/80;
Ankle-Brachial index 0.75
LDL was 178,CRP was 4.2 mg/dL (Normal:
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Case Discussion (Contd.)
At this stage the patient became pain free;Troponin T was 0.08(Nl
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Clinical Pathway A
Case Discussion
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Patient was admitted to hospital18 hours after admission, the patient underwent
cardiac catheterization. He had been loadedwith Anti-platelet (Clopidogrel), & was given an
infusion of GPIIB-IIIA Blocker (Tirofiban), inaddition to Aspirin and Heparin.
He was found to have :
- 90% mid left anterior descending (LAD),- The lesion in the LAD had ulcerated,roughened angiographic appearance.
-Normal RCA & Circumflex.
Case Discussion
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24 Hr. @
Hep,antiplatele
t includingIIb/IIIa and
Plavix/Asp.
Coronary Angiography
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Clinical Pathway B
Case Discussion
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In Emergency room, Patient was feeling
well, became pain free and declined
admission to hospital. He was discharged on Aspirin and
Cholesterol lowering Medications
Case Discussion
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One day later he experienced severe chest
pain which persisted for >20 minutes.
He was brought to Emergency department
with severe pain, and profuse sweating. The
following EKG was recorded
Case Discussion
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ST-Segment Elevation Myocardial Infarction
(STEMI)
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Patient was cleared for Pharmacologicintervention
Intravenous Tenecteplase was administeredintravenously with initial partial improvement of
pain and diminishing ST elevation! Pain quickly returned with re-elevation of ST
segments
Case Discussion