Case No. 23Case No. 23Lin, I-Chen(Tina)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”N

PH at 6am, 15”u”NPH at 6pm• ECG showed: ST elevation anteroseptal

and lateral areas.

Diagnosis: Acute Myocardial Diagnosis: Acute Myocardial infarction & Hypoglycemiainfarction & 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 insulin-dependent 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 SymptomsSigns 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 vom

iting

• Associated diaphoresis or sweating • Syncope or near-syncope without other cause • Impairment of cognitive function without other cause

Laboratory examinationLaboratory 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 toDetect Myocardial Infarction

Analysis Normal Range

Total creatinine phosphokinase (CK) 30-200 U/L

CK, MB fraction 0.0-8.8 ng/mLCK, MB fraction percent of total

CK0-4%

CK, MB2 fraction < 1 U/L

Troponin I 0.0-0.4 ng/mL

Troponin T 0.0-0.1 ng/mL   

ManagementManagement

pharmacologic regimen:• 1.antithrombotic agents• 2.beta-adrenoceptor blockers• 3.angiotension-converting enzyme

inhibitor (ACEI)• 4.other agent: Nitrates

1.antithrombotic agents1.antithrombotic agentsPlatelet inhibitor: Aspirin• MOA: inhibits synthesis of thromboxane A2

Anticoagulant: Heparin• MOA: inhibitor antithrombin IIIFibrinolytics: tPA• MOA: lyze thrombus by formation of serine proteose p

lasminGlycoprotein IIb/IIIa Antagonists: Abviximab• MOA: inhibit of fibrinogen

Adverse effect: bleeding, GIT symptom

2.beta-adrenoceptor blockers2.beta-adrenoceptor blockersEx: 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: Nitrates4.other agent: NitratesEx: Nitroglycerineroute: Sublingual tablet, Spray, Transdermal or paste, In

travenous• MOA: releases Nitric Oxide→↑cGMP→relaxation• adverse effect: throbbing headache, flushing of the fa

ce, 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 pressure3.Eat a low fat diet4.more fruit and vegetable diet5.Control DM6.Exercise daily to improve heart fitness.