Acute Coronary Syndrome

MED II 2013
Case Discussion

ACS case discussion
Objectives
Understand difference of mechanisms and
outcomes of myocardial ischemia @ special clinical
scenarios
Underscore co-existence of multiple vascular bed
involvement by athero-thrombosis
Recite the basic patho-biologic elements &
expression spectrum of Acute coronary syndrome
Explore bench-bedside implementation of
diagnostic and therapeutic strategies in ACS.
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 Myocardial
infarction at age 56)
He has been asymptomatic except for Brief and mild
chest pain , during brisk walk one day before
Presented to Emergency department with Acute and
severe chest pain lasting 10 min
EKG: ST elevation, normalized after 10 minutes


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:<.2.0),
normal electrolytes, BUN 15, creatinin 1.2
Patient was advised to stop smoking, take Aspirin and
follow low salt,& low fat diet

Case Discussion(contd.)
Case Discussion (Contd.)
At this stage the patient became pain free;
Troponin T was 0.08(Nl<0.03); CRP was 5.5 mg/dL;
EKG Normal





Clinical Pathway A
Case Discussion




Patient was admitted to hospital
18 hours after admission, the patient underwent
cardiac catheterization. He had been loaded
with Anti-platelet (Clopidogrel), & was given an
infusion of GPIIB-IIIA Blocker (Tirofiban), in
addition 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

24 Hr. @
Hep,antiplatele
t including
IIb/IIIa and
Plavix/Asp.

Coronary Angiography




Clinical Pathway B
Case Discussion
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
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
ST-Segment Elevation Myocardial Infarction
(STEMI)
Patient was cleared for Pharmacologic
intervention
Intravenous Tenecteplase was administered
intravenously with initial partial improvement of
pain and diminishing ST elevation!
Pain quickly returned with re-elevation of ST
segments
Case Discussion