1. Clinical case no. 22 Presenter: Lin,Huei-Hsiu (Caroline) (Caroline)

2. A 50 y/o male came to the hospital accompanied by relatives clutching of his chest complaining of sever pain over substernal area radiating to the left jaw and left arm. This was associated with cold clammy perspiration and shortness of breath. A 50 y/o male came to the hospital accompanied by relatives clutching of his chest complaining of sever pain over substernal area radiating to the left jaw and left arm. This was associated with cold clammy perspiration and shortness of breath. This accompanied with on and off chest pain which was noted to have occurred by the time he was diagnosed to be diabetic with FBS: 300mg/dl and total cholesterol of 250mg 2 years ago. This accompanied with on and off chest pain which was noted to have occurred by the time he was diagnosed to be diabetic with FBS: 300mg/dl and total cholesterol of 250mg 2 years ago. Was given: Was given: Nitroglycerin 5mg Nitroglycerin 5mg Metoprolol 50 mg ½ tablet Metoprolol 50 mg ½ tablet Asprin 325mg 1 tab stat Asprin 325mg 1 tab stat

3. Diagnosis: Angina Pectoris -> AMI Angina Pectoris -> AMI Heavy, squeezing pain of precordial or substernal area Heavy, squeezing pain of precordial or substernal area Radiates to back neck jaw groin Radiates to back neck jaw groin Occurs in Men 50-60 and in women 65-75 Occurs in Men 50-60 and in women 65-75

4. Angina pectoris 3 types: 3 types: 1. Classic Angina/Stable/angina of effort-imbalance of oxygen caused by exertion and relieved by rest 1. Classic Angina/Stable/angina of effort-imbalance of oxygen caused by exertion and relieved by rest 2.Unstable angina/acute coronary syndrome- episodes of angina at rest caused by increased epicardial tone, platelet clots, and thrmobi. Ass w MI and death 2.Unstable angina/acute coronary syndrome- episodes of angina at rest caused by increased epicardial tone, platelet clots, and thrmobi. Ass w MI and death 3. variant/angiospastic angina/Prinzmetal- transient spasm of coronary artery, relieved by nitrates and calcium channel blockers 3. variant/angiospastic angina/Prinzmetal- transient spasm of coronary artery, relieved by nitrates and calcium channel blockers

5. Symptoms clutching chest clutching chest Severe substernal pain radiating to left jaw and arm Severe substernal pain radiating to left jaw and arm Clammy cold Clammy cold Shortness of breath Shortness of breath

6. Signs: LVH LVH VS: VS: BP 160/100CR 90/min BP 160/100CR 90/min ECG findings: ST Elevation ECG findings: ST Elevation

7. Risk factors: LVH -> Heart Failure LVH -> Heart Failure Diabetic 300mg/dl -> Atherosclerosis -> MI Diabetic 300mg/dl -> Atherosclerosis -> MI High cholesterol 250mg High cholesterol 250mg BP: Moderately High 160/100 BP: Moderately High 160/100 Dyspnea Dyspnea Elder 50 year old patient Elder 50 year old patient

8. Treatment: Nitroglycerin 50mg Nitroglycerin 50mg Nitrate and nitrite drugs: Nitrate and nitrite drugs: Release NO -> relaxing the muscles, * vasodilation Release NO -> relaxing the muscles, * vasodilation Sublingual, oral, buccal, spray, IV, transderaml, ointment Sublingual, oral, buccal, spray, IV, transderaml, ointment Decrease ventricular vol and pressure Decrease ventricular vol and pressure Decrease arterial pressure Decrease arterial pressure Decrease ejection time Decrease ejection time Vasodilation of epicardial coronary artery Vasodilation of epicardial coronary artery Increased collateral flow Increased collateral flow Result: Myocardial O2 requirement decreased and improved perfusion Result: Myocardial O2 requirement decreased and improved perfusion

9. Treatment: Metoprolol 50 mg ½ tablet Metoprolol 50 mg ½ tablet Beta Blocker Beta Blocker Decrease HR and BP Decrease HR and BP Increase perfusion Increase perfusion Decrease rate of contraction Decrease rate of contraction Recommended within 12 hours of MI symptoms continued indefinitely. Admission reducing mortality. Recommended within 12 hours of MI symptoms continued indefinitely. Admission reducing mortality.

10. Treatment: Asprin 325mg 1 tab stat Asprin 325mg 1 tab stat Antiplatelet Agents: Antiplatelet Agents: Given immidiately on recognition of MI signs and symptoms to be continued daily. It is a *COX 2 inhibitor inhibiting the formation of thromboxane 2 Given immidiately on recognition of MI signs and symptoms to be continued daily. It is a *COX 2 inhibitor inhibiting the formation of thromboxane 2

11. THE END