Case Review : Acute ST Elevation MI

A 46 years Male from Islamabad came to ER with complains of Epigastric  and retrosternal pain for 16 hours. The pain was constricting type , continuous, radiating to left arm and neck, and not relieved in any position. It was associated with Shortness of breath. He had 3 episodes of Vomiting and sweating. He also complains of palpitation. Headache +, LOC followed the event and he was rushed to ER. Bowel/Bladder habits were Normal.
He had no history of chest pain before but he is a smoker, 9-10 sticks per day for past 30 years. He occasionally consumed alcohol.
He doesn’t give history of HTN, or Diabetes Mellitus.
On Examination at ER:

• GC-  patient conscious but in agony.
• Vitals- Blood pressure- 100/80 mmHg, Pulse= 64/minute, RR=32/min , Temperature=Normal
• Cardinal signs- JVP- raised

1. Chest- Bilateral Normal Vesicular Breath Sound, No added sounds
2. CVS- S1 and S2 Normal, No mumur
3. P/A-  soft, non-tender, no organomegaly

• ECG showed- ST-T changes specific of Antero-lateral Myocardial Infarction. Q waves.

ST elevation in chest leads

• Total Count- 11,700 with N-87 and L-10, Hemoglobin=13.4 g%
• Cardiac Enzymes= CPK MB= 109 U/L after 4 hours CPKMB=421U/L, Troponin I was positive.

Diagnosis- Anterolateral MI
Immediate Management-

1. Oxygen
2. Aspirin
3. Clopidogrel
4. Inj Morphine
5. LMW Heparin
6. Isosorbide dinitrate
7. Isosorbide Mononitrate
8. Alprazolam
9. Cremaffin

Patient could not be Thrombolysed because it was past recommended time and Q waves in ECG were seen by arrival.
CCU course-
day1 -Patient developed hypotension . ECG showed Inferior wall extension.Inotropes were started.
day 2-Couplets were seen, Hr-120 beats/min and was controlled by beta-blocker Metoprolol low dose
day 3- Inotropes were tapered gradually. Patient’s condition improved.
ECHO done.
Planned for Coronary Angiography. Possible CABG.

Popular Medications

(Drugs listed alphabetically by generic name with brand name in parentheses)  ACE (angiotensin converting enzyme) inhibitors-Angiotensin converting enzyme inhibitors are used to treat high blood pressure. They cause the blood vessels to relax and become larger and, as a result, blood pressure is lowered. When blood pressure is reduced, the heart has an easier time pumping blood. This is especially beneficial when the heart is failing. ACE inhibitors also cause the process of hypertensive- and diabetes-related kidney diseases to slow down and prevent early deaths associated with high blood pressure. ACE inhibitors cannot be taken during pregnancy since they may cause birth defects. Generic ACE inhibitors are available. acetaminophen (brand name: Tylenol)-A pain reliever and fever reducer. The exact mechanism of action of acetaminophen is not known. Acetaminophen relieves pain by elevating the pain threshold (that is, by requiring a greater amount of pain to develop before it is felt by a person). Acetaminophen reduces fever through its action on the heat-regulating center of the brain. Generic is available. alprazolam (brand name: Xanax)- A benzodiazepine sedative that causes dose-related depression of the central nervous system. Alprazolam is useful in treating anxiety, panic attacks, insomnia, and muscle spasms. Generic is available. amoxicillin (brand names: Amoxil, Polymox, Trimox)-An antibiotic of the penicillin type that is effective against different bacteria such as Haemophilus influenzae, Neisseria gonorrhoea, Escherichia coli, Pneumococci, Streptococci, and certain strains of Staphylococci, particularly infections of the middle ear, tonsillitis, throat infections, laryngitis, bronchitis, and pneumonia. Amoxicillin is also used in treating urinary tract infections, skin infections, and gonorrhea. Generic is available. atenolol (brand name: Tenormin)-A medication that blocks the action of a portion of the involuntary nervous system that stimulates the pace of the heartbeat. By blocking the action of these nerves, atenolol reduces the heart rate and is useful in treating abnormally rapid heart rhythms. Atenolol also reduces the force of heart muscle contraction, lowers blood pressure, and is helpful in treating angina. It is also used for the prevention of migraine headaches and the treatment of certain types of tremors. Generic is available. bupropion (brand names: Wellbutrin, Zyban, Wellbutrin SR)-An antidepressant medication that affects chemicals within the brain that nerves use to send messages to each other. These chemical messengers are called neurotransmitters. The neurotransmitters that are released by nerves are taken up again by the nerves that release them for reuse (referred to as reuptake). Many experts believe that depression is caused by an imbalance among the amounts of neurotransmitters that are released. Bupropion is unrelated to other antidepressants. It works by inhibiting the reuptake of the neurotransmitters dopamine, serotonin, and norepinephrine, resulting in more of these chemicals being available to transmit messages to other nerves. Bupropion is unique in that its major effect is on dopamine. Wellbutrin and Wellbutrin SR are used for the management of depression. Zyban has been approved as an aid to patients who want to quit smoking. Generic is not available. cephalexin (brand names: Keflex, Keftabs)-A semisynthetic cephalosporin antibiotic that is chemically similar to penicillin. Cephalexin is effective against a wide variety of bacterial organisms, such as Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Escherichia coli, particular involving infections of the middle ear, tonsillitis, throat infections, laryngitis, bronchitis, and pneumonia. Cephalexin is also used in treating urinary tract infections and skin and bone infections. Generic is available. ciprofloxacin (brand name: Cipro)-An antibiotic that stops multiplication of bacteria by inhibiting the reproduction and repair of their genetic material (DNA). Ciprofloxacin is used to treat infections of the skin, lungs, airways, bones, and joints that are caused by susceptible bacteria. Ciprofloxacin is also frequently used to treat urinary infections caused by bacteria such as Escherichia coli. Ciprofloxacin is effective in treating infectious diarrheas caused by E. coli, Campylobacter jejuni, and shigella bacteria. Generic is not available. citalopram (brand name: Celexa)-An antidepressant medication that affects neurotransmitters, the chemical messengers within the brain. Neurotransmitters manufactured and released by nerves attach to adjacent nerves and alter their activities. Thus, neurotransmitters can be thought of as the communication system of the brain. Many experts believe that an imbalance among neurotransmitters is the cause of depression. Citalopram works by preventing the uptake of one neurotransmitter, serotonin, by nerve cells after it has been released. The reduced uptake caused by citalopram results in more free serotonin being available in the brain to stimulate nerve cells. Citalopram is in the class of drugs called selective serotonin reuptake inhibitors (SSRIs). Generic is not available. clonazepam (Klonopin)-Used to treat anxiety, clonazepam works by enhancing the response to gamma-aminobutyric acid (GABA) in the brain, a neurotransmitter that inhibits the activity of many parts of the brain. It is believed that too much activity can lead to anxiety. By enhancing the response to GABA, clonazepam inhibits activity in the brain and relieves the short-term symptoms of anxiety. Clonazepam should not be taken during pregnancy, as the effects are known to cause damage to the fetus. More than half of those who take clonazepam experience the side effect of sedation. Generic clonazepam is available. codeine (brand name: Empirin 2, 3, 4, Tylenol 2, 3, 4, Tylenol with Codeine Elixir)-Codeine is a pain reliever used to temporarily relieve mild to severe pain. Codeine has the ability to impair thinking and physical ability necessary for driving, and, when combined with alcohol, the impairment can be worsened. Those taking codeine have the ability to become dependent on the drug mentally and physically. Those patients allergic to aspirin and pregnant mothers should not take codeine. Codeine often is combined with acetaminophen (Tylenol) or aspirin to add to its effectiveness. Side effects of codeine include light-headedness, dizziness, nausea, vomiting, shortness of breath, and sedation. Generic codeine is available. doxycycline (brand name: Vibramycin)-A synthetic broad-spectrum antibiotic that is derived from tetracycline and is effective against a wide variety of bacteria, such as Haemophilus influenzae, Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia psittaci, Chlamydia trachomatis, and Neisseria gonorrhoea. Doxycycline is particularly helpful for treating respiratory tract infections and for treating nongonococcal urethritis (due to ureaplasma), Rocky mountain spotted fever, typhus, chancroid, cholera, brucellosis, anthrax, syphilis, and acne. Generic is available. fluoxetine (brand name: Prozac)-A class of antidepressant medications that affects chemical messengers within the brain. These chemical messengers are called neurotransmitters. Many experts believe that an imbalance in these neurotransmitters is the cause of depression. Fluoxetine is used in the treatment of depression and obsessive-compulsive disorders. Fluoxetine is believed to work by inhibiting the release of or affecting the action of serotonin. Generic is available. hydrocodone/acetaminophen (brand names: Vicodin, Vicodin ES, Anexsia, Lorcet, Lorcet Plus, Norco)-A narcotic pain reliever and a cough suppressant that is similar to codeine and is used for the relief of moderate to moderately severe pain. The precise mechanism of pain relief by hydrocodone and other narcotics is not known. Acetaminophen is a nonnarcotic pain reliever and fever reducer. It relieves pain by elevating the pain threshold and reduces fever through its action on the heat-regulating center of the brain. Generic is available. hydroxyzine (brand names: Vistaril, Atarax)-An antihistamine with anticholinergic (drying) and sedative properties that is used to treat allergic reactions and to relieve nasal and nonnasal symptoms such as those from seasonal allergic rhinitis. Histamine is released by the body during several types of allergic reactions and to a lesser extent during some viral infections, such as the common cold. When histamine binds to its receptors on cells, it causes changes within the cells that lead to sneezing, itching, and increased mucus production. Antihistamines compete with histamine for cell receptors; however, when they bind to the receptors, antihistamines do not stimulate the cells. In addition, antihistamines prevent histamine from binding and stimulating the cells. Generic is available. ibuprofen (brand names: Advil, Motrin, Medipren, Nuprin)-A traditional nonsteroidal anti-inflammatory drug (NSAID) that is effective in treating fever, pain, and inflammation in the body. As a group, NSAIDs are nonnarcotic relievers of mild to moderate pain of many causes, including injury, menstrual cramps, arthritis, and other musculoskeletal conditions. Generic is available.

levothyroxine sodium (brand names: Synthroid, Levoxyl, Levothroid, Unithroid)-A synthetic version of the principal thyroid hormone thyroxine (T4), which is made and released by the thyroid gland. Levothyroxine sodium is used to treat hypothyroidism and to suppress thyroid hormone release in the management of cancerous thyroid nodules and growth of goiters. Thyroid hormone increases the metabolic rate of cells of all tissues in the body. Thyroid hormone helps to maintain brain function, food metabolism, and body temperature, among other effects. Generic is available.

lisinopril (brand name: Zestril, Prinivil)-Lisinopril is an ACE inhibitor that works to lower blood pressure by relaxing and enlarging blood vessels. It also is used to treat heart failure. Lisinopril should be taken at the same time each day in order to ensure consistent blood levels. Pregnant mothers should avoid lisinopril, and it is important to avoid taking lisinopril within two hours of an antacid since antacid binds the lisinopril and prevents it from being absorbed into the body. Side effects of lisinopril include dizziness that is felt when the blood pressure begins to drop, and kidney damage as well. Those taking potassium supplements or diuretics that cause potassium to be retained by the body should not take lisinopril because blood potassium levels may rise to dangerously high levels. Generic lisinopril is available.

lithium (brand name: Lithobid)-Since the 1950s, lithium has been used in the treatment of bipolar disorder as well as depression. Lithium is a mineral that has a positive charge, similar to sodium, potassium, calcium and magnesium. It works by interfering inside cells with other minerals with positive charges such as potassium, calcium and magnesium. Lithium impacts the brain by affecting both the concentrations of tryptophan and serotonin within the brain's cells, and neurotransmitters, chemical messengers that nerves use to communicate with each other. It is recommended that lithium be taken together with food. The full clinical effects of lithium are seen about 2-3 weeks after beginning treatment. Goiters of the thyroid gland develop in one out of every 25 persons taking lithium. Generic lithium is available.

lorazepam (brand names: Ativan)-An antianxiety medication in the benzodiazepine family. Lorazepam and other benzodiazepines act by enhancing the effects of gamma-aminobutyric acid (GABA) in the brain. GABA is a neurotransmitter, a chemical that nerves in the brain use to send messages to one another. GABA inhibits activity in many of the nerves of the brain, and it is thought that this excessive activity is what causes anxiety and other psychological disorders. Lorazepam has fewer interactions with other medications and is felt to be potentially less toxic than most of the other benzodiazepines. Lorazepam is also used to treat insomnia and panic attacks. Generic is available.

meloxicam (brand name: Mobic)-Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) that is used in the treatment of inflammation due to osteoarthritis and rheumatoid arthritis. Meloxicam, like other NSAIDs, reduces the pain, tenderness and swelling caused by inflammation by preventing the formation of chemicals that contribute to inflammation. Individuals who are prone to asthma attacks, hives or have an allergy to aspirin and other NSAIDs should not take meloxicam. Aspirin should not be taken with meloxicam as such a combination raises the risk for developing ulcers of the stomach or small intestine. Generic meloxicam is available..

metformin (brand name: Glucophage)-Approved by the FDA in 1994, metformin is used to lower blood glucose levels in type 2 diabetes in adults and children. Metformin also reduces complications of diabetes including heart disease, blindness and kidney disease. When used alone, metformin does not increase insulin levels in the blood and, therefore, does not result in extremely low blood glucose levels. Metformin increases the effects that insulin has on the liver, muscle, fat, and other tissues. As a result, the reduced levels of insulin have more of an effect than they otherwise would. Metformin also has been used to prevent diabetes from worsening and also has been used to treat polycystic ovaries. Side effects of metformin include nausea, vomiting, gas, bloating, diarrhea, and loss of appetite. Generic metformin is available.

methotrexate (brand names: Rheumatrex, Trexall)-A drug that is capable of blocking the metabolism of cells (an antimetabolite). As a result of this effect, methotrexate has been found to be helpful in treating certain diseases associated with abnormally rapid cell growth, such as cancer of the breast and psoriasis. Recently, methotrexate has been shown to be effective in inducing miscarriage (for example, in patients with ectopic pregnancy). This effect of methotrexate is attributed to its action of killing the rapidly growing cells of the placenta. Methotrexate has also been found to be very helpful in treating rheumatoid arthritis, although its mechanism of action in this illness is not known. Methotrexate seems to work, in part, by altering aspects of immune function that may play a role in causing rheumatoid arthritis. Generic is available.

methylprednisolone (brand name: Medrol, Depo-Medrol)-Methylprednisolone is a synthetic corticosteroid that is used to reduce inflammation in inflammatory diseases such as arthritis, lupus, Crohn's disease, and ulcerative colitis. The body produces corticosteroids naturally in the adrenal glands. Methylprednisolone may be used during pregnancy as it does not cause abnormalities in the fetus. However, using methylprednisolone for long periods of time can cause the body to stop producing its own corticosteroids. This can lead to a serious problem, i.e., inadequate amounts of corticosteroids, if the methylprednisolone is stopped for any reason. Generic methylprednisolone is available.

metoprolol (brand names: Lopressor, Toprol XL)-A medication that blocks the action of a portion of the involuntary nervous system. The sympathetic nervous system stimulates the pace of the heart beat. By blocking the action of these nerves, metoprolol reduces the heart rate and is useful in treating abnormally rapid heart rhythms. Metoprolol also reduces the force of heart muscle contraction, lowers blood pressure, and is helpful in treating angina. Generic is available.

metronidazole (brand name: Flagyl)-Metronidazole is an antibiotic used to fight infections caused by a class of bacteria called anaerobic bacteria as well as some parasites. Metronidazole is used for infections of the small intestine, amebic liver abscesses, dysentery and trichomonas vaginal infections. It also is used to treat infections of the colon caused by the bacterium, Clostridium difficile. Taking metronidazole with alcohol is dangerous as it can cause nausea, vomiting, cramps, flushing and headache. Pregnant mothers and nursing mothers should not use metronidazole. Side effects of metronidazole, although they are few, include seizures and nerve damage that can lead to numbness and tingling of the hands and feet. Generic metronidazole is available.

naproxen (brand names: Naprosyn, Naprelan, Anaprox, Aleve)-A traditional nonsteroidal anti-inflammatory drug (NSAID) that is effective in treating fever, pain, and inflammation in the body. As a group, NSAIDs are nonnarcotic relievers of mild to moderate pain of many causes, including injury, menstrual cramps, arthritis, and other musculoskeletal conditions. Generic is available.

phentermine (brand names: Adipex-P, Fastin, Obenix, Oby-Trim)-An appetite suppressor that decreases appetite by possibly changing brain levels of serotonin. Phentermine is a nervous system stimulator like the amphetamines, causing stimulation, elevation of blood pressure, and increased heart rates. Phentermine is used for short periods, along with diet and behavior modification, to treat obesity. Generic is available.

prednisone (brand names: Deltasone, Liquid Pred, Prednisolone, Pediapred Oral Liquid, Medrol)-An oral, synthetic corticosteroid that is used for suppressing the immune system and inflammation. Synthetic corticosteroids mimic the action of cortisol (hydrocortisone), the naturally occurring corticosteroid that is produced in the body by the adrenal glands. Corticosteroids have many effects on the body, but they most often are used for their potent anti-inflammatory effects, particularly in conditions in which the immune system plays an important role. Such conditions include arthritis, colitis, asthma, bronchitis, certain skin rashes, and allergic or inflammatory conditions of the nose and eyes. Generic is available.

tramadol (brand name: Ultram)-A pain reliever (analgesic) that is used in the management of moderate to moderately severe pain. Its mode of action resembles that of narcotics, but tramadol has significantly less potential for abuse and addiction than narcotics. Tramadol is as effective as narcotics in relieving pain, but it does not depress respiration, which is a side effect of most narcotics. Generic is not available.

Inspirational Quotes 2

Healing the Hardest of Hearts (By: Aisha Bhoori)

The ambulance was shrieking, and I was the unlucky patient being hurriedly transported to the local hospital. My body lay on a stretcher inside the vehicle, pain shooting through my left arm.

“It looks like a massive heart attack,” I heard one of the paramedics whisper. Not knowing the true severity of my situation, I shut my eyes, desperately praying to Ar-Rahman (The Merciful) to have mercy on His slave.

…..

I impatiently tugged at the oxygen tubes in my nose, wondering when I would be able to escape from this prison the public decreed was a hospital.  A cardiologist soon strolled into my room, her brown eyes vibrant with empathy as she laid my chart down on the side counter and turned towards me, exclaiming, “As-salaamu `alaykum Aisha.”

Believing her kindness to be merely the facet of a friendly facade, I brusquely muttered an inaudible “Wa `alaykum as-salaam .”

The doctor tucked a strand of loose hair back in her hijab and began the arduous task of diagnosing me.

“The EKG was abnormal. We found some…disturbing signs. The irregular rate at which your heart is beating and the atypical electrical activity occurring are typical signs of a very discontent heart. We believe you are suffering from qalb-ul-qasiyyah, a hardened heart.”

With this revelation she looked at me expectantly, but my apathetic eyes merely gazed at her in boredom. I was too tired—too weary—too hopeless to care about the dire condition of my heart.

“Aisha?” she asked, giving me a questioning glance. “This is a very curable disease, you know. I once suffered from it too.”

With this revelation my eyes flickered with mild interest. But even then, I was suffocating under the burden of my despair and believed whatever “cure” the doctor was referencing had ceased to exist.

Understanding my cynical mindset, she began narrating her story.

“I was in a situation very similar to the one in which you are now. I was spiritually lost, wandering about with this immense pain in my soul, and my heart was reaping the effects. One day, I collapsed from the sheer magnitude of helplessness and sadness, and I was rushed into a hospital, just like the one in which we are today.”

I was fully awake at this point, and my eyes perceived the doctor in a different light. Curious as to how she managed to recover from the disease, I asked, “How did you get better?”

A knowing smile played on her lips: “Never forget Aisha—Allah subhanahu wa ta`ala (exalted is He) says in the Qur’an, “Surely with every hardship comes ease” . But to answer your question more directly, I recovered through tawbah , dhikr   and du`a’   . These three things are the key to maintaining a relationship with Allah (swt). And in every situation, you have to have tawakkul⁷ . Believe me, when you put your trust in Allah (swt) and not in other people, or a drug or a pill, the results are miraculous; tawakkul is an alleviation of stress and despair. ”

“But I already do all of those things. I pray five times a day too, ” I grumbled. ” And look where I am now.”

“I used to feel the same way,” she responded. The cardiologist’s eyes seemed to see through my exterior into my conflicted interior. “But just think for a moment. Do we really believe La ilaha illallah ? I think the problem I had, and the problem our Ummah  as a whole suffers from, is that our hearts haven’t born witness to the shahada  . Our iman  is merely lip service; it is neither manifested in our deeds nor nestled in our hearts. Rasulullah   ﷺ (peace be upon him) used to make tawbah over 70 times a day. We barely say 3 heartfelt astagfirullah‘s a day. How often do we return to Allah (swt) when we know we have strayed off the straight path, and are distant from Him?”

The doctor paused for a few seconds, and then turned back to me, asking a strange question with a seemingly obvious reply: “What do you think about when you pray?”

“Allah (swt) of course, ” I answered, matter of factly. But, seeing her skeptical look, I answered again.

“Well, usually my mind wanders, and I start to think about what my friend told me at lunch, or what I’m going to do for my science fair project, or what outfit I should wear to the party on Saturday. It’s hard to focus on Allah (swt),” I admitted.

“Good. You realize sometimes your mind strays from the remembrance of Allah (swt). It’s a problem that everybody struggles with. And it’s the cause of inefficient salah . Salah is meant to be a protection for us against sin—a protection against the ever persistent whisperings of Shaytan (the devil). But, more often than not, it becomes monotonous, ritualistic movements of the body, in which our minds remember everything but Allah (swt). And this inefficient salah leads to a very lost, discontent soul that wonders why it has ceased to feel alive.”

Recognizing the truth in her words, I asked, “How can I start remembering Allah (swt)?”

“Simple. Dhikr and du`a’; strive to remember Allah (swt), and make du`a’. Ask As-Sami` (The One Who Hears) to bless you with the remembrance of Him. And remember it is recorded in a hadith   that ‘Whoever does not ask of Allah (swt), he is angry with him.’ Ask Allah (swt) and expect to be answered, because Allah (swt) loves to hear and answer the supplications of his humble servants.”

By this time I had shifted positions from laying on my back, to sitting upright, my head leaning against a few fluffed out pillows. The telemetry machine beeped encouragingly; my heart was beginning to beat at a more normal pace. I felt as I did after a rigorous cardio workout or an exhausting yet satisfying  game of basketball at the YMCA.

The cardiologist was quiet—lost in her thoughts. It seemed as if her speech had ended. Her hand was on the doorknob and she began to open the door.

“Where’s my prescription?” I quickly asked, assuming she had forgotten.

She merely chuckled. “I think I’ve given you everything you need to recover from this disease and have a qalbin salim—a sound heart. Read the Qur’an. Remember Aisha, in the Qur’an there is a healing—a healing that can heal even the hardest of hearts. ”

And with that, she opened the door and exited the room.