CAS-REPORTACUTE CORONARY SYNDROME

Dr.DINH XUAN DIEMA&E department

FVH

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

Clinical examination : (07:20 AM) P = 80/min; BP = 160/90 mmHg; RR = 18/min T= 36.9oC; 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.

Time Clinical signs paraclinical signs Treatment

7h20 As 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)

ECG 1 (07h30)

Time Clinical signs Paraclinical signs Treatment08h 2nd left chest

discomfort

BP = 160/100mmHg

ECG 2: see next slide - Lovenox 40mg/0.4ml 60mg (SC) ( 1mg/kg)

- Aspegic 250mg/A (IV)

08h30 Improvement

TA= 150/85mmHg

ECG 2 (08h)

Time Clinical signs Paraclinical signs Treatment09h BP = 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)

ECG 3 (09h)

Time Clinical signs Paraclinical signs Treatment

10h30 Stable 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.

AFFIRMATIVE DIAGNOSTIC : Non-ST elevation MI ( NSTEMI or subendocardial MI) / HTN, DM2, hypercholesterolemia.

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

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

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 factor Points Patient• Age > 65• CAD risk factors ( ≥ 3)Family histryHypertensionCurrent smokerHigh cholesterolDiabetes• Known CAD ( stenosis ≥ 50%)• Previous chronic use of aspirin• 2 episodes of rest angina in past 24hs• Elevated cardiac makers

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