1. CAS-REPORT ACUTE CORONARY SYNDROME Dr.DINH XUAN DIEM A&E department FVH

2.  Male 54 yrs coming to A&E at 7:10 AM 17/12/2009 due to vomiting & epigastric pain  Past history : HTN, gout (irregular treatment),smoker  Medical history : Vomiting 2 times + mild epigastric pain + sweating + tired yesterday morning ( after breakfast) >> Took medicines  better. Vomiting + epigastric pain again at 2 AM this morning, more and more aggravation + very tired >> FVH at 07:10 AM

3.  Clinical examination : (07:20 AM) P = 80/min; BP = 160/90 mmHg; RR = 18/min T= 36.9 o C; SpO2 = 97%, W= 65kg Pain score = 4, Glasgow =15. No signs of heart, lung, abdomen. Only functional signs: Nausea, tired Mild epigastric pain, radiation to chest No dyspnea, no sweating.

4. TimeClinical signs paraclinical signsTreatment 7h20As above Blood tests : CBC, CRP, SGOT, SGPT, CKMB, troponine I, glycémia, créatininemia, iono, lipidémia. NS, Nexium 7h30- palpation - Left chest discomfort - Tired ECG 1 ( see next slide)- Oxygen 5l/min - Nitromint 2doses ( spray) - Plavix 75mg 4tabs (PO)

5. ECG 1 (07h30)

6. TimeClinical signsParaclinical signsTreatment 08h 2 nd left chest discomfort BP = 160/100mmHg ECG 2: see next slide- Lovenox 40mg/0.4ml 60mg (SC) ( 1mg/kg) - Aspegic 250mg/A (IV) 08h30Improvement TA= 150/85mmHg

7. ECG 2 (08h)

8. TimeClinical signs Paraclinical signsTreatment 09hBP = 160/100cmHg Troponine I = 1,02 CKMB = 208 LDH = 553, SGOT = 223 Gly = 1,98, Ct = 2,66 ECG 3 (see next slide) Echocardiography : LV kinetic trouble (-), EF = 62%, PAPs=50mmHg Chest X-ray = Cardiomegaly Abdominal US = N Cardiologist ‘s opinion : D-Dimeres, HbA1C control and hospitalization in ICU Lopril 25mg (PO)

9. ECG 3 (09h)

10. TimeClinical signs Paraclinical signsTreatment 10h30Stable situation: TA = 140/80mmHg chest discomfort (-) D-Dimer = 531 HbA1C = 6.7 consultation with dr. David >> transfered to Tam Duc hospital for further spécialized treatment.

11. AFFIRMATIVE DIAGNOSTIC : Non-ST elevation MI ( NSTEMI or subendocardial MI) / HTN, DM2, hypercholesterolémia. In Tam Duc hospital : Immediate coronarography >> Result :obstruction of small branch Circonflex and restricted branch of left coronary artery (70%) Disposition : medical treatment without immediate angioplasty

12. Remarks : Atypical AMI Risk factor : Male Smoker Diabetes HTN Family history ( Father died due to MI). Intermediate risk ( TIMI risk score = 3). Good improvement with medical treatment. Secondary angioplasty for prognostic amelioration

13. TIMI risk score Risk level : 1-2 : low(4.7-8.2%) – 3-4 : intermediate(13.2- 19,9%) – 5-7 : high(26.2-40.9%) Risk factorPointsPatient Age > 65 CAD risk factors ( ≥ 3) Family histry Hypertension Current smoker High cholesterol Diabetes Known CAD ( stenosis ≥ 50%) Previous chronic use of aspirin 2 episodes of rest angina in past 24hs Elevated cardiac makers 11 111111 1111 1  1 ? 1