Documente Academic
Documente Profesional
Documente Cultură
Presenters: Hakimah Khani' Binti Suhaimi Nurul 'Izzah Binti Sodri Supervisor: Dr Patrick
23/4/14 Seminar Room Wad Kenanga 12 Hospital Sultan Haji Ahmad Shah (HoSHAS)
Outline
Introduction Pathogenesis Diagnosis Risk stratification Management
Pre-Hospital In-Hospital Post-Hospital
Case file
ACS - An Introduction
Incidence: 141 per 100,000 population/year, and the inpatient mortality rate is approximately 7%. Definition: A spectrum of UA / NSTEMI and STEMI. The clinical presentation will depend on the acuteness and severity of coronary occlusion.
Pathogenesis
Pathogenesis of Atherosclerosis
Accumulation of lipid-laden macrophages and smooth muscle cells, so-called foam cells
As the atherosclerotic plaque grows, production of macrophage proteases and neutrophil elastases within the plaque can cause thinning of the fibromuscular cap that covers the lipid core.
Increasing plaque instability coupled with blood-flow shear and circumferential wall stress lead to
plaque fissuring or rupture, especially at the junction of the cap and the vessel wall activation, adhesion and aggregation of platelets + activation of clotting cascade formation of occlusive thrombus
Pathogenesis of ACS
Atherosclerotic plaque rupture, fissure or ulceration with superimposed thrombosis and coronary vasospasm Etiology of plaque fissure or rupture is still unclear. Possible causes: inflammation, infection, uncontrolled BP and smoking. Primary UA/NSTEMI = ACS occurring de novo Secondary UA/NSTEMI can occur due to: - increased myocardial oxygen demand (eg fever, tachycardia, thyrotoxicosis) - reduced coronary blood flow (hypotension) - reduced myocardial oxygen delivery (eg anaemia or hypoxemia)
Diagnosis
History Physical examination Electrocardiography Cardiac biomarkers Other diagnostic modalities. E.g. echocardiogram
Management
The goals of management are: Immediate relief of ongoing ischemia and angina Prevention of recurrent ischemia and angina Prevention of serious adverse cardiac events
Pre-hospital Management
In-Hospital Management
UA/NSTEMI in (CKD)
-blockers in UA/NSTEMI
Lipid-lowering drugs
Case File
DEMOGRAPHIC DETAILS
Chief Complaint
Mr Mohd Ali, 64-year-old gentleman, with underlying DM, HPT, IHD, COPD, and gastritis was admitted with the chief complaint of left-sided chest pain for 3 days prior to admission.
Left-sided chest pain X 3/7 - occurs at rest, radiated to left jaw and arm, heaviness in nature - lasted for >20mins - S/L GTN X4 per day - partially relieved - pain score 4-5, on 19/4/14 - pain score 10/10 - a/w diaphoresis, SOB, palpitation, and failure sx: orthopnea, PND In KK, BP 132/67, PR 63, given T. aspirin 300mg STAT
4/23/2014
4/23/2014
Physical Examination
Physical Examination
Alert, comfortable, not in respiratory distress. Pink. Fair hydrational status. No xanthelasma/xanthomata V/S: Afebrile BP 130/70 PR 60, regular, good volume RR 20 sPO2 99% under R/A DXT 5.0 JVP not raised CVS S1, S2, no added heart sounds, no murmurs Lungs clear, equal air entry P/A soft, non-tender No pedal edema
Investigations
4/23/2014
Serial ECGs
ECG STAT in KK
4/23/2014
ECG STAT in ED
4/23/2014
4/23/2014
ECG in ward
4/23/2014
4/23/2014
4/23/2014
4/23/2014
4/23/2014
4/23/2014
4/23/2014
4/23/2014
Surely there is in the body a small piece of flesh; if it is good, the whole body is good, and if it is corrupted, the whole body is corrupted, and that is surely the heart.
- Prophet Muhammad SAW, narrated by Abu Abdullah an-Nu'maan ibn Basyiir RA
4/23/2014
Thank You
4/23/2014