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.