Case 006: Acute Coronary Syndromes

PATIENT PRESENTATION

Chief Complaint

“I need help! I think I am having a heart attack.”

History of Present Illness

A patient presents to the emergency department with electrocardiographic changes, clinical signs, symptoms, and laboratory tests consistent with acute coronary syndrome. The patient is diagnosed with acute myocardial infarction, admitted to the hospital, and undergoes percutaneous coronary intervention with intracoronary stent placement.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What type of acute coronary syndrome (ACS) is this - ST-segment elevation myocardial infarction or non-ST-segment elevation ACS?

   Hint: See Clinical Presentation and Diagnosis in PPP

2. What signs, symptoms, laboratory tests, and diagnostic tests confirm the diagnosis of myocardial infarction (MI)?

   Hint: See Clinical Presentation and Diagnosis in PPP

3. What are the presenting signs, symptoms and diagnostic tests that identify this patient at high-risk for death, MI or failing initial pharmacotherapy that suggest a treatment strategy of urgent/early angiography and intracoronary stent deployment is the preferred treatment strategy over an ischemia-guided treatment strategy?

   Hint: See Treatment, Table 9-1, and Figure 9-3 in PPP

4. What were this patient’s risk factors for developing ischemic heart disease (IHD) (prior to this hospital admission)?

   Hint: See Clinical Presentation and Diagnosis and Table 8-2 in PPP

5. What is the recommended duration of dual antiplatelet therapy following acute MI with percutaneous coronary intervention before switching to single antiplatelet therapy?

   Hint: See Treatment and Table 9-3 in PPP along with reference 1 below

FOLLOW-UP

The patient presents to his cardiologist 2 weeks following discharge. His BP is 142/92 mm Hg, pulse 55 bpm, and he is afebrile. He has no angina and no signs or symptoms of heart failure. His chemistry panel includes A1C 7.2%, potassium of 4.2 mEq/L (4.2 mmol/L) and SCr 1.07 mg/dL (95 µmol/L).

What recommendations would you make to the physician regarding his pharmacotherapy regimen?

Hint: See Outcome Evaluation and Table 9-5 in PPP along with reference 2 below

CASE SUMMARY

Global Perspective

According to the World Health Organization, cardiovascular disease (CVD) is the most common cause of deaths worldwide. Cardiovascular disease accounts for 17.9 million deaths, or 32% of deaths globally each year. Ischemic heart disease, a type of CVD most often caused by myocardial infarction, is the most common CVD, accounting for 16% of all deaths globally each year.

Key References