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Case No. 23
Lin, I-Chen(Tina)
• A 30 y/o female, frail looking, pale
came in stretcher borne with chief
complaint of weakness and vomiting.
An hour PTC (prior to consultation),
she was noticed to be uncomfortable
with cold clammy perspiration
immediately after breakfast.
• BP-80/60, RR-24/m
• Diabetic for 5 years, on insulin:
20”u”NPH at 6am, 15”u”NPH at 6pm
• ECG showed: ST elevation
anteroseptal and lateral areas.
Diagnosis: Acute Myocardial
infarction & Hypoglycemia
• ID: Acute myocardial infarction (MI) is defined as
death or necrosis of myocardial cells. MI means
that part of the heart muscle suddenly loses it's
blood supply.
• This accelerated form of atherosclerosis occurs
regardless of whether a patient has insulindependent or noninsulin-dependent diabetes.
• The proportion of painless AMI is great in
patient with diabetes mellitus and it increase
with age.
• May present as sudden-onset breathlessness
which may progress to pulmonary edema.
Signs and Symptoms
• Chest pain described as a pressure sensation, fullness,
or squeezing in the midportion of the thorax
• Radiation of chest pain into the jaw/teeth, shoulder,
arm, and/or back
• Associated dyspnea or shortness of breath
• Associated epigastric discomfort with or without nausea
and vomiting
• Associated diaphoresis or sweating
• Syncope or near-syncope without other cause
• Impairment of cognitive function without other cause
Laboratory examination
• 1.Electrocadiogram(ECG): The first test is
the ECG, which may demonstrate that a MI is in
progress or has already occurred
• 2.Blood Tests: Blood tests can be performed to
detect evidence of myocardial cell death.
a.creatine phosphokinase (CK)
b.MB isoenzyme of CK (CKMB)
c.cardiac-specific troponin T (cTnT)
d.cardiac-specific troponin I (cTnI)
• 3.Echocardiography:
The echocardiogram can be helpful in identifying
which portion of the heart is affected by a MI,
and which of the coronary arteries is most likely
to be occluded.
Normal Values of Blood Tests to
Detect Myocardial Infarction
Analysis
Total creatinine
phosphokinase (CK)
CK, MB fraction
CK, MB fraction percent of total
CK
CK, MB2 fraction
Normal Range
30-200 U/L
0.0-8.8 ng/mL
0-4%
< 1 U/L
Troponin I
0.0-0.4 ng/mL
Troponin T
0.0-0.1 ng/mL
Management
pharmacologic regimen:
• 1.antithrombotic agents
• 2.beta-adrenoceptor blockers
• 3.angiotension-converting enzyme
inhibitor (ACEI)
• 4.other agent: Nitrates
1.antithrombotic agents
Platelet inhibitor: Aspirin
• MOA: inhibits synthesis of thromboxane A2
Anticoagulant: Heparin
• MOA: inhibitor antithrombin III
Fibrinolytics: tPA
• MOA: lyze thrombus by formation of serine
proteose plasmin
Glycoprotein IIb/IIIa Antagonists: Abviximab
• MOA: inhibit of fibrinogen
Adverse effect: bleeding, GIT symptom
2.beta-adrenoceptor blockers
Ex: Metoprolol, Atenolol, Esmolol
• MOA: inhibit Beta-1 receptor
• adverse effect: bradycardia, hypotension
3.angiotension-converting enzyme
inhibitor (ACEI)
ACEI: Captopril, Enalapril
• MOA: inhibit angiotension-converting enzyme
• adverse effect: Dry cough
4.other agent: Nitrates
Ex: Nitroglycerine
route: Sublingual tablet, Spray, Transdermal or
paste, Intravenous
• MOA: releases Nitric Oxide→↑cGMP→relaxation
• adverse effect: throbbing headache, flushing of
the face, dizziness, postural hypotension
5) Tx hypoglycemia
non-pharmacologic regimen:
1.Supplemental Oxygen: Supplemental oxygen
should be administered to patients with
symptoms and/or signs of pulmonary edema or
pulse oximetry reading less than 90% blood
oxygen saturation.
2.Control blood pressure
3.Eat a low fat diet
4.more fruit and vegetable diet
5.Control DM
6.Exercise daily to improve heart fitness.