Acute Myocardial Infarction

Killip type I

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Patient’s profile

Name : Razak b Abdul Hamid

Gender : male
Age : 48 years old
Race : Malay
Nationality : Malaysian
Occupation : Felda settler
Address : Tasik Bera
Marital status : married
Date of admission : 22 June 2009
Date of clerking : 24 June 2009

Presenting complaint

Chest pain for 2 days associated with sweating.

History of presenting illness

The patient named Razak with known case of hypertension was presented to accident and
emergency department with 2 days history of chest pain. The pain was retrosternal and
crushing in nature. The pain radiated to right and left shoulder, to the right elbow and to the
back. The chest pain was associated with profuse sweating.The pain started as he woke up in
the morning. The pain was intermittent and mild during that day. The pain resolved
temporarily as he woke up in the next morning but reappear in mid afternoon at the time he
was performing his prayer. The pain was mild and intermittent at the beginning but became
worse and continuous in the late evening. He used traditional oil to relieve the pain but it only
works for only 2 to 3 minutes, then the pain reappear again.
He had no palpitation, no shortness of breath, no ankle edema, no orthopneoa and no
giddiness during the episodes of chest pain.
He went to Klinik Rakyat at 7pm and he was given two tablet of glyceryltrinitrate (GTN). He
claimed that the pain reduced and was referred to Hospital Temerloh.
Patient previously has 3 episodes of chest pain in past one month. However, the chest pain
resolved spontaneously and short in duration.

Systemic Review

Respiratory system
No cough, no rhinitis and no sinusitis.

Gastrointestinal system
He has no pain at abdomen. No alteration in bowel habit; defecation was about 2 times per
day. There were no vomiting, diarrhea and hematemesis.

Genitourinary system
No alteration in urination habit; urination was about 4-5 times a day. No polydypsia, no
hematuria, no urgency and no urinary incontinence.

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Musculoskeletal system
No joint pain or swelling. There also no muscle stiffness and abnormal gait.

Central Nervous System

He had no tremor, loss of sensory, migraine, diplopia, fit, automatism, paralysis, and speech
defect or body incoordinations.

Past Medical History

He was admitted to Hospital Mentakab 20 years ago due to motor vehicle accident. He was a
known case of hypertension since 1 year ago. He claimed that he is compliant to
antihypertensive medication.

Past Surgical History

He had no known past surgical history.

Drug History and allergies

He had no known drug and food allergy. Currently he is taking antihypertensive medication
which cannot be specified.

Family History
His mother had diabetes mellitus and claimed on insulin treatment.

Social History
He is married with 7 children. Currently he lives with his wife and one of his children in a
single storey house at Tasik Bera. He works as Felda settler and an active smoker for 10
years. He smoke about 15 cigarettes per day and he not drink alcohol.

Physical examination

General inspection
The patient was alert and conscious, propped up 45o on the bed. The chest moves with the
respiration. He was not tacypnoeic and not in respiratory distress. There were no jaundice,
pallor and cyanosis. The hydration was good.

Vital signs:

Blood pressure : 126/82 mmHg

Pulse rate : 92/min Regular rhythm and good volume
Respiratory rate : 20 breaths/min
SpO2 : 99.0 % under nasal prong
Temperature : 370C (afebrile)

Hands
There were tar staining at the index finger and middle finger at right hand. There were no
palmar erythema, no asterixis, no clubbing and no peripheral cyanosis. Capillary refill time
was normal (less than 2 seconds).

Face

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No conjuctival pallor, no sign of jaundice and no evidence of Horner’s syndrome. No central
cyanosis. The hydration and dentition was good.

Neck
Trachea was centrally located. Jugular venous pressure was not raised and no palpable lymph
nodes at the neck region.

Specific Cardiovascular Examination

Inspection
The shape of the chest was normal, no deformities and symmetry bilaterally. There were
three ECG patches at his chest. There were traumatic scar at the left side of the chest. The
scar size was 2cmx1cm located at second intercostals space at anterior axillary line.

Palpation
The apex beat was palpable at fifth intercostals spaces at midclavicular line and not
displaced. No parasternal heave and no thrills.

Auscultation
On auscultation of the praecordium, S1 and S2 can be heard over 4 areas (mitral, tricuspid,
pulmonary and aortic). No added sound and no murmur.

Systemic examination

Respiratory system
The lungs were clear. No rhonchi and no crepitation.

Gastrointestinal tract
Abdomen was soft and non tender. No organomegaly.

Musculoskeletal system
The tone was normal, power 5/5 and reflexes were normal for both upper limb and lower
limb and for both right side and left side. Barbinski sign was negative.

Neurological system
All cranial nerves were intact. Reflexes and sensory component were intact.

Summary

The patient named Razak complained of chest pain for two days associated with profuse
sweating. He had no dyspneoa ,no paroxysmal nocturnal dyspneoa, no palpitation and no
ankle swelling. He is an active smoker for 25 years old and smoke about 10 cigarettes per
day. The risk factors for this patient are male, smoking and underlying hypertension.

Diagnosis

Provisional diagnosis : Myocardial infaction

Differential diagnosis : Myocardial infarction

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 Unstable angina

Investigations

Full Blood Count

level Limits units

WBC 11.8 4.0 -10 103/mm3
RBC 5.17 4.5 -6.5 106
HGB 16.3 13.0 – 17.0 g/dL
HCT 46.0 40.0 – 54.0 %
PLT 239 150 – 500 103/mm3
Impression: WBC value slightly high. The other values in normal range.

Cardiac Enzyme

LDH 2071 U/L (240-461)

CK 402 U/L (24-170)
AST 74 U/L (0-40)
Impression: All cardiac enzyme were raised

Arterial blood gas

PO2 81 mmHg
PCO2 33 mmHg
pH 7.3
Impression: pH was normal although PO2 & PCO2 were low.

Electrolytes

Ca 2.3 mmol/L (2.0 – 2.6)

Mg 2+
1.1 mmol/L (0.8 – 1.0)
Inorganic phosphate 1.1 mmol/L (0.8 – 1.5)
Impression: Mg2+ slightly high. Ca and inorganic phosphate were in normal range.

Chest X-Ray

The chest X-ray was taken in anteroposterior position. The exposure was good. The airway
located in the middle of the chest and not deviated. There was no bone fracture. The cardiac
size was normal. The costophrenic angle was sharp. The lungs were clear. No consolidation
and no sign of pneumothorax.
Impression: The chest x-ray was a normal chest x-ray.

Electrocardiogram (ECG)

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Three ECG had taken on three separate occasion. However, there was no changes for all the
three ECG. The ECG showed ST elevation at lead V1, V2 and V3, Q wave in lead I and both T
wave inversion and ST depression in lead II, lead III and aVF.
Impression: Infarction at anterior part of right atrium and septum, and there was ischemia at
inferior part of the heart.

Echocardiogram (EEG)

There were no right and left hypertrophy. Both left and right atrium functions normally. All
four valves of the heart (tricuspid, pulmonary, mitral and aortic) valves function normally. No
regurgitation and no stenotic valves. But the systolic function of left ventricle function
satisfactorily. The midanterior septum and basal anterior septum were hypokinetic. No
pericardial effusion.

Discussion

Myocardial infarction (MI) is the irreversible necrosis of heart muscle secondary to

prolonged ischemia. This usually results from an imbalance of oxygen supply and demand1.
Increased cardiac enzymes in the circulation indicate myocardial necrosis. Myocardial
infarction is a part of acute coronary syndromes (ACSs), which also includes unstable angina
and non–ST-elevation MI (NSTEMI). Myocardial infarction may lead to impairment of
systolic function or diastolic function and to increased predisposition to arrhythmias and
other long-term complications.

Cardiovascular diseases cause 12 million deaths throughout the world each year, according to
monitoring report of the World Health Organization year 1991-93. They are the major cause
of death in adults everywhere. Approximately 6.3 million deaths due to heart disease
occurred in 1990 worldwide, which represents 29% of all deaths. The prevalence of coronary
artery disease (CAD) is increasing rapidly in non-industrialized countries1.

From the history, physical examination and investigation, the patient might have acute
myocardial infarction. This is due to sudden chest pain when he woke up in the morning.
Then the pain disappeared and reappeared during that day. The episodes of chest pain also
associated with profuse sweating. ECG recording also showed changes in the conduction of
the heart; infarction at anterior part of right atrium and septum, and there was ischemia at
inferior part of the heart.

For this patient, unstable angina is unlikely because there were ECG changes in three
separate occasions in addition to raised cardiac enzyme in the blood. ECG recording may be
normal in unstable angina patient in addition to normal or raised cardiac enzyme in the blood.

Besides all of the above investigation, I would like to suggest for lipid profile test. I expect
lipid will be high in this case because hyperlipidaemia is a strong risk factor for development
of atherosclerotic plaque and further cause ischemic heart disease.

Killip classification is used to assess sign of heart failure after a patient had diagnosed with
myocardial infarction. Individuals with a low Killip class are less likely to die within the first
30 days after their myocardial infarction than individuals with a high Killip class2. Patients
are ranked from Killip class I to Killip class IV which has highest mortality rate.

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This patient is classified under Killip class I because he had no clinical sign of signs of heart
failure. The patient that is classified under this class, they has mortality rate about 8%.

Plan and Management

Initial therapy for acute myocardial infarction is to restore myocardial perfusion as soon as
possible to salvage as much of the jeopardize myocardium as possible.

Further treatments are needed to:

1. Restoration of the balance between the oxygen supply and demand to prevent further
ischemia
2. Pain relief

3. Prevention and treatment of any complications that may arise.

Non-pharmacological

1. Cessation of smoking
2. Dietary modification
3. Daily activities

Pharmacological

1. IV streptokinase 1.5 mill over 1 hour

To remove a pathologic intraluminal thrombus or embolus that has not been dissolved
by the endogenous fibrinolytic system.

2. T. plavix 300mg and 75mg OD

To reduce atherosclerotic events (for recent stroke,recent MI or established peripheral
arterial disease)

3. T. cardiprin 100mg OD
An antiplatlet used for prophylaxis against stroke, further vascular occlusion and deep
vein thrombosis.

4. T. lovastatin 200mg OD
A lipid lowering agent used to reduce risk of development of new lesions and total
occlusions.

5. T. metoprolol 25mg OD
A beta-blocker that has antiarrhythmic properties and to reduce myocardial oxygen
demand secondary to elevations in heart rate and inotropy.

6. IV zantact 50mg
To prevent peptic bleeding due to usage of salycylate.

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References

1. Samer Garas, MD, FACC, Chief of Cardiology, Department of Interventional

Cardiology, St Vincent's Hospital
2. http://en.wikipedia.org/wiki/Killip_class