Cardiology Series: Case 2

ANSWERS WILL BE POSTED TOMORROW 3/1/17 at 18:00 CET

An 81-year old lady presents to A&E with shortness of breath and unbearable chest pain, that she described as being compressive in nature.
It came within a matter of minutes, after climbing a flight of stairs at home. The pain radiated to her left shoulder.
In her past medical history, you note that she suffers from Type II Diabetes Mellitus and is a heavy smoker.

1. What would be your differential diagnosis ? Most likely put first.

You order an immediate ECG. The result is seen below.

Image result for anteroseptal MI ecg

2. Describe the ECG result.

3. What are the other primary investigations that you would order ? Describe the typical findings of the most likely diagnosis mentioned in 1.

4. How would you manage this patient in the initial phase ?

5. How would you further manage this patient in the ward ?

6. List common complications that may arise in this patient.

 Source: https://www.ncbi.nlm.nih.gov/pubmed/28072597


1. Acute Myocardial Infarction (most likely)
Pericarditis
Myocarditis
Aortic Dissection
Pulmonary Embolism
Gastroesophageal Reflux Disease

2. This patient has an Anteroseptal Myocardial Infarct. ST elevations can be seen in leads V2-V5.

3. Routine Blood Investigations
Full Blood Count, Lipid Profile. Glucose test. Renal Function. Urinalysis. Urea and Electrolytes.

Cardiac Enzymes
CK-MB and Troponin.
Troponin levels: Rise initially within 3-12H from the onset of chest pain and peak after 1-2 days.
CK-MB: Rise initially within 3-12 hours from onset of chest pain and peak after a day.

Chest X-ray
Look for cardiomegaly, pulmonary oedema and aortic rupture.

4. Initial Phase

  • Oxygen 100% by mask unless contraindicated
  • Aspirin 300mg chewed
  • Glyceryl Trinitrate Sublingual
  • Analgesia: Morphine and Metoclopramide

5. In the ward, treat as an acute ST elevation MI

  • Angioplasty or thrombolysis. Thrombolysis has to be done early within 24 hours.
  • Beta-blockers: Atenolol unless contraindicated
  • ACE-inhibitors: Perindopril within 24 hours of onset of MI and especially if evidence of heart failure
  • Consider an anti-platelet drug: Clopidogrel

6. Complications

  • Cardiac Arrest
  • Unstable Angina
  • Heart Failure due to bradycardia or heart block
  • Tachyarrhythmias
  • Pericarditis
  • DVT and PE
  • Systemic Embolus
  • Left Ventricular Aneurysm

 

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