CASE REPORT SESSION

“Acute Coronary Syndrome”

By: Group 2
Patient identity
• Patient Name : Mr. RH
• Room : Room 3
• Med.Rec Number : 575634
• Sex : Man
• Age : 53 y.o.
• Religion : Islam
• Occupation :-
• Address : Kp. Cipanji RT04/01 Cihampelas
• Date of entry : February. 10th 2019
• Date of examination : February. 15th 2019
Chief Complaint
• Chest pain
Special Anamnesis
• Present Illness :
A sudden chest pain felt since 3 hours before entering the
hospital. The pain is described as dull like heaviness on the chest, that
radiates to the left arm and back. The chest pain occur after he walked
down the street. Resting do not relieved the pain. The pain continously
and become severe, so he went to the ER. This pain is not accompanied
by heartburn. Chest pain is accompanied by shortness of breath,
without sound of wheezing. Shortness of breath does not improve or
reduce if the patient sleeps sideways to the right or left and does not
worsen with a deep breath. There’s no history of chest trauma. Patient
denied that he was wake up at night because feel shortness of breath,
or feel out of breath when does activity or while he was take a rest.
• Past Medical History
This is the third time the patient experiences the pain. The first
experience was 2 years ago, and last was 8 month ago, but the pain
was relieved after took a rest. The patient had hypertension since 10
years ago and was uncontrolled and rarely took medication. Diabetes
mellitus is rejected. There is no history of hypercholesterolemia. The
patient's family has no family history of heart disease.

• Personal and Social History

Patients claim to rarely exercise. Patients often consume salty
and high-fat foods like innards. The patient was a heavy smoker since
20 years ago as much as 1 pack per day and has stopped since 2
months ago.
 Physical Examination
• General Conditions Vital Signs
• Awareness : compos mentis
Blood pressure : 160/100 mmHg
• Pain impression : moderate
Pulse : 92 x / mins
• Sleep : supine, 1 pillow
• Height : 156 cm Respiration : 26 x / mins
• Weight : 50 kilograms Respiratory Type : Abdominothoracal
• BMI : 20,5 kg/m2
Temperature : 36,8 °C
• Nutrional level : Normal
Review of System
• Head
a. Skull : Normocephal d. Ears : There are no abnormalities
e. Nose : There is no abnormalities
b. Face : Puffy Face (-) f. mouth:
c. eyes: - Lips : No abnormalities
- Eyelids : eyelid edema - / - - Gums and teeth : No abnormalities
- Tongue : No abnormalities
- Sclera : icteric - / -
- Oral cavity : No abnormalities
- Conjunctiva : anemic - / - - Neck cavity : There is no abnormalities
- Pupil : Round, Isokor
- Eye Lens : Clear
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• Neck
a. Inspection
- trachea : Deviation (-)
- thyroid gland : Not look bigger
- Lymph Nodes : Not look bigger
- Widening of vein : Not visible
b. Palpation
- Thyroid gland : No enlargement
- Lymph Nodes : No
- Stiff neck : No
- Jugular venous pressure: 5 ± 2 cmH2O
- HJR : none
• Armpit : no abnormalities enlargement
- Tumours : None
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Front Thorax Palpation
- Skin : No abnormalities
Inspection - Musculature : No abnormalities
- Shape : Symmetric - Intercostal space : No abnormalities
- Vocal Fremitus : No abnormalities
- Movement : Symmetric - Ictus cordis : Palpable
- Intercostal space : Normal Percussion
- Percussion comparison: sonor / sonor
- Skin : No abnormalities - Heart Boundaries :
- Musculature : No abnormalities Left = ICS V left midclavicularis + 1cm lateral LMCS
Right = ICS IV right parasternal line
- Ictus cordis : Not visible Upper = ICS II left sternal line
- Mammae : No abnormalities Auscultation
Respiratory Sounds : VBS R=L
Vocal resonance : normal / normal
Heart sounds : S1 & S2 murni regullar
murmur (-), gallop (-)
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• Back Thorax • Percussion

• Inspection
Percussion comparison: sonor / sonor
Shape : Symmetric
Movement : Symmetric displacement:
Skin : No abnormalities
Left = Vertebrae thorakal X
Musculature : No abnormalities
• Palpation Right = Vertebrae thorakal XI
Intercostal space : Not widened or narrowed • Auscultation
Musculature : No abnormalities
Musculature : no abnormalities Respiratory Sounds : VBS R=L
Vocal fremitus : normal / normal Vocal resonance : normal / normal
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• Abdomen • Palpation
• Inspection wall : smooth
Shape : Flat Tenderness : none
Mass / tumor : none
Skin : No abnormalities Hepar : no palpable
Umbilicus : indented Spleen : no palpable
• Auscultation Troube space : empty
Bowel : (+) normal Kidney : Ballotement - / -
• Ekstremities
Bruit : None Warmness acral: CRT < 2sec
Edema : -/-
Laboratory Result
Diff Count
Hematologi 10-02-2019 Basofil 0,2%
Hb 15,4 g/dL Eosinofil 0,7%
Eritrosit 5x106/uL Segmen 75%
Leukosit 9.100/mm3 Limfosit 17%
Hematokrit 45,2% Monosit 6,1%
Trombosit 225.000/mm3 Random Blood Glucose 79 mg/dL
MCV,MCH.MCHC Ureum 33 mg/dL
MCV 84,8 fL Kreatinin 1,3 mg/dL
MCH 29.1 Pq Trigliserida 148 mg/dL
MCHC 34.4 g/dL LDL 144 mg/dL
RDW 13.8 % Troponin I 0,77
ECG
ECG interpretation
• Ryhthm : Sinus Ryhthm
• Frequency : 125 x/minute
• Axis : Normoaxis
• Wave abnormalities : P pulmonal on lead II, III, and aVF,
ST depresion on lead I, aVL, V5, V6,
T-inverted on lead vak. V5, V6
• ECG impression : Sinus Rythm 125x/minutes, normoaxis, Right
Atrium Hypertrophy (RAH), LVH, High
Lateral Myocard Infarct
Differential Diagnosis :
• Non ST Elevation Myocard Infarct
• ST Elevation Myocard Infarct
• Unstable Angina Pectoris

Clinical Dianosis :
• Acute Coronary Syndrome

Anatomical Diagnosis :
• High Lateral Myocard Infarct

Etiologic Diagnosis :
• Atherotrombotic plaque
Therapy
• Nonpharmacologic Therapy
1. Bed Rest
2. O2 via nasal kanul 2-4 lpm
• Education:
 Lifestyle changes : increase mild physical activity 30-45 min / day
min 5 days a week like walking leisurely
 Reduce foods containing fat (Diet)
 Control body weight
Pharmacologic
• AnalgetiC : Morphine 20mg
• Antiplatelet : Aspirin tabs 75 mg
Clopidogrel tabs 100 mg
• Nitrates : Isosorbide dinitrate 5 mg
• Antikoagulan : Enoxaparin 1 mg/kg
• Angiotensin Receptor Blocker : Candersarten 1x8 mg
• Statin : Atrovastatin 1x 20mg (0-0-1)
Test Recommendation
• Thorax Photo
• Electrolit
Prognosis
• Quo ad vitam : dubia ad bonam
• Quo ad functionam : dubia
Acute Coronary
Syndrome
What is Acute Coronary Syndrome?
Stable Angina Unstable Angina NSTEMI STEMI
Definitions
• Unstable angina:
• An unprovoked or prolonged episode of chest pain
raising suspicion of acute myocardial infarction (AMI)
• Without definite ECG or laboratory evidence
• NSTEMI:
• Chest pain suggestive of AMI
• Non-specific ECG changes (ST depression/T
inversion/normal)
• Laboratory tests showing release of troponins
• STEMI:
• Sustained chest pain suggestive of AMI
• Acute ST elevation or new LBBB

* ALS handbook 6th Edn

Pathophysiology
Atherosclerosis
• Epithelial injury
• Migration of
monocytes/macro
phages
• LDL lipids
consumed 
foam cells
• Growth factors 
smooth muscle,
collagen,
proteoglycans
• Atheromatous
plaque forms
Clinical features

• Chest pain Palpitations

• Tachycardia or bradycardia Sweaty

• Nausea Hypotension or hypertension
• Heart murmurs Vomiting
• Dyspnoea Syncope
Distinguishing features

• SA: • UA: • NSTEMI: • STEMI:

plaque platelet platelet complete
formation adhesion aggregation occlusion
 Precipitated by stress or • At rest or minimal exertion
exertion
• Lasts >20 minutes
 Lasts <20 minutes
• Often accompanied by other s/s
 Relieved by GTN or • Poor GTN relief
resting
Risk Factors
Non-Modifiable Modifiable
• Increasing age • Smoking
• Gender (male) • Obesity
• Diet
• Ethnicity
• Lack of exercise
• Family History
• High serum cholesterol
• ?Diabetes
• Hypertension
• ? Diabetes
Differential Diagnosis
Cardiac Respiratory
• MI • Pulmonary embolism
• Angina • Pneumothorax
• Pericarditis • Pneumonia
• Aortic dissection

Chest pain

GI Musculoskeletal
• Oesophageal spasm • Costochondriasis
• GORD • Trauma
• Pancreatitis
Investigations
Bedside Obs, ECG, BM
Blood FBC, UE, LFT, lipids, cardiac enzymes, amylase, CRP
Imaging CXR
Special Echo, angiography

UA NSTEMI STEMI
Normal troponin Raised troponin Raised troponin
* ECG normal * ST depression * ST elevation
* Possible ST * Can be normal * Hyperacute T waves
depression * Possible T wave * New LBBB
inversion * T inversion (hours)
* Q waves (days)

* ST elevation is >1mm in limb leads and >2mm in chest leads

Important ECG findings
 Where is the problem?

Inferior II, III, aVF Right coronary

Lateral I, aVL (+V5-6) Left circumflex (or LAD)
Anterior V1-2 septum, V3-4 apex, V5-6 ant/lat LAD
Posterior ST depression in V1-3 Left circumflex or right
coronary
Management
A Patent?
B Oxygen (aim for sats 94-98%), auscultate, RR
C IV access (+/-fluids), HR, BP
D GCS, pupils, cap blood glucose
E Expose
Common ACS management
• Morphine (5-10mg slow IV injection)
• Oxygen (titrate sats to need)
• Nitrates - GTN spray (400mcg = 1 spray) or tablet
(1mg)
• Aspirin (300mg chewed)

• Plus an antiemetic i.e.

Metoclopramide 10mg IV

* BNF 64
Unstable angina & NSTEMI
• LMWH i.e. Enoxaparin 1mg/kg BD or Fondaparinux 2.5mg OD
• Clopidogrel 300mg loading dose
• Beta blocker - atenolol 5mg
• Nitrates – usually IV
• Consider coronary angiography within 72 hr
Scoring systems
GRACE scoring
• Predicts 6/12 mortality in
NSTEMI patients
• Age
• HR and systolic BP
• Killip class (CCF, pulmonary
oedema, shock)
• Cardiac arrest on admission
• Elevated cardiac markers
• ST segment change
TIMI
• Risk of cardiac events in next
30 days
• Age >65
• Known coronary artery
disease
• Aspirin in last 7/7
• Severe angina (>2 in 24hr)
• ST deviation >1mm
• Elevated troponins
• > CAD risk factors
STEMI
• TIME IS MUSCLE
• Percutaneous coronary intervention (Primary PCI)
• ‘Call to balloon time’ of 120 minutes
• Requires clopidogrel 600mg loading dose
• Rescue PCI after failed thrombolysis
• Thrombolysis
• Streptokinase / alteplase / tenecteplase…
• Contraindications
• Clopidogrel 600mg loading dose AND LMWH
• Beta blocker i.e. Atenolol
• ACE inhibitor i.e. Lisinopril
Longer-term management
• Continuous ECG monitoring as inpatient/ CCU
• Aspirin 75mg OD (lifelong)
• Clopidogrel 75mg (1 year)
• Beta blocker (1 year - lifelong)
• ACE inhibitor
• Statin
• Modification of risk factors
Complications

Early <72hr Late

• Death • Ventricular wall rupture
• Cardiogenic shock • Valvular regurgitation
• Heart failure • Ventricular aneurysms
• Ventricular arrhythmia • Cardiac tamponade
• Myocardial rupture • Dresslers syndrome
• Thromboembolism • Thromboembolism
THANK YOU