AMI case (7/12/07)

[excalibur]

---

Members do not see this ad.

I thought since there are a lot of us surfing on here, we could just give our interesting cases, so we can all refresh our skills and maybe help one another. Just anyone who wants to talk about an interesting case, post it and date it, and fellow SDN interns can discuss how they would go about it.

Background...I'm on Cardiology at a private hospital. I mostly shadow, but I go see consults, and sometimes write recommendations, but I never write orders. Plus, my attending who is super nice, he co-signs my notes, and he just writes the orders. Well, here's a case he told me to see, while he had to go do some cath cases (he's an interventional cardiologist) at a neighboring hospital.

Cardiology consult for CP
58 y/o man who is disheveled and somewhat indiscernable appears to be complaining of SOB more to me than CP as the consult says. He does appear to be laboring with breathing. Pt claims to me that the SOB started 2 days ago and he never had CP during this time. 2 pints/wk drinker, 20+ pk yr smoker. PE: RRR, nl S1 S2...Bibasilar rales...Abd benign...VSS.

Labs: CE's are markedly elevated...Troponin is 56 (nl is <0.03), CK total, CK MB and CK index are all high. Myoglobin is like 400. EKG showed slight ST depression in V2, V3, V4.

Although this pt will need to eventually go to the cath lab, it is not immediate as in STEMI. So, what is the medical mgmt of this pt as he waits for his cath? By this I mean, what drugs (dose and route) should this patient be on if he is not already?

 

[Purifyer]

I thought since there are a lot of us surfing on here, we could just give our interesting cases, so we can all refresh our skills and maybe help one another. Just anyone who wants to talk about an interesting case, post it and date it, and fellow SDN interns can discuss how they would go about it.

Background...I'm on Cardiology at a private hospital. I mostly shadow, but I go see consults, and sometimes write recommendations, but I never write orders. Plus, my attending who is super nice, he co-signs my notes, and he just writes the orders. Well, here's a case he told me to see, while he had to go do some cath cases (he's an interventional cardiologist) at a neighboring hospital.

Cardiology consult for CP
58 y/o man who is disheveled and somewhat indiscernable appears to be complaining of SOB more to me than CP as the consult says. He does appear to be laboring with breathing. Pt claims to me that the SOB started 2 days ago and he never had CP during this time. 2 pints/wk drinker, 20+ pk yr smoker. PE: RRR, nl S1 S2...Bibasilar rales...Abd benign...VSS.

Labs: CE's are markedly elevated...Troponin is 56 (nl is <0.03), CK total, CK MB and CK index are all high. Myoglobin is like 400. EKG showed slight ST depression in V2, V3, V4.

Although this pt will need to eventually go to the cath lab, it is not immediate as in STEMI. So, what is the medical mgmt of this pt as he waits for his cath? By this I mean, what drugs (dose and route) should this patient be on if he is not already?

Im a cardiology nerd so I'll add my thoughts.

disclaimer: read uptodate instead of listening to a co-intern rant

Which troponin are you using? I assume tnt given the <0.03 reference range thing. I've never heard of a tnt of 56. I never measure myoglobin either, dont know how specific/sensitive that is. Im assuming this isn't some weird systemic muscle injury (a bit odd that CKMB is still raised 48 hours after event, but with a troponin of 56.. who knows.) just a bog standard NSTEMI. Is he diabetic?

Anyway he should be clopidogrel loaded (depending on your boss, loading 300 vs 600mg PO stat.. I believe 600mg is the more 'research backed' dose). Obviously started on aspirin as well, morphine IV (eg 2-5mg or whatever you want) prn pain.. there is no improvement in mortality/morbidity so no point if not in pain. Beta blockers are thought to be .. good.. in the immediate setting of MI (assuming haemodynamically stable, not in HF - your intro doesnt make it clear whether or not you think he is)... you've missed the boat regarding IV dosing, chuck him on some metoprolol short acting 50mg and titrate upwards. Assuming good renal function, start him on an ACE. I dont know whether there are any ACEI better than any other... Depending on the boss I tend to use Cilazapril (start 2.5 then titrate up) or Quinapril (0.5). In a slightly different setting (Im currently in CT surgery) I use captopril alot because its short acting. A statin is also a good move although not important in the short term, eg simvastatin 40mg nocte.

Obviously he should have been on enoxaparin (or equivalent) 1mg/kg BD (or 1.5mg/kg OD.. I get confused between PE and MI... I think in PE you can use both dosages) theres no point starting this 48 hours post MI though.

Your intro doesn't shed too much light on comorbidities, cardiac hx, cardiac risk factors etc. Obviously these would need to be improved as much as possible as well. Theres good evidence that tight glycaemic control (regardless if IDDM/NIDDM/ impaired glucose tolerance) with insulin infusion improves outcome, but my CCU couldn't be ****ed with this as the nursing was too intense.

Just be wary that your ST depression V2-V4 isnt merely the reciprocal changes seen in the posterior infarct.

 

[Adcadet]

A few thoughts...

First things firs - airway, breathing, circulation, defib stickies on if you can, get on a monitor, get some O2 on him.

Why is he in the hospital? Unless he's been worked up before for CP, I think you need to at least think about covering a few other things. Should you get a CXR? I'm thinking so, especially given the SOB, but also if you think dissection is a possibility. Probably a pCXR as you'll have lots of things going on Could this be a PE - if so, get a CT-PE, but probably after starting a few things that would be OK for both PE and ACS.

From what you've said already, sounds like an NSTEMI already. But it would be nice to get an old ECG and make sure this isn't all old. Assuming this is looking like UA/NSTEMI (UA as no history of angina), then I think a few things are in order...

I think the evidence now clearly favors an early invasive strategy, so he's headed for the cath lab. So you should probably be talking with your cards attending and calling the cath lab. While that's happending...

How about getting some ASA onboard - 325 mg po chewed. I've heard people say to give clopidrogrel only if ASA allergic, but CREDO and CURE showed benefit on top of ASA at least for those going for cath. So I might give the 300 mg loading dose followed by the usual 75 mg per day after that. Of course, if this guy ends up needing CABG the CT surgeons will hate you (or love you if their schedules were full already).

He should also be on heparin or, as Purifyer mentioned, LMWH which is slightly better but I've never seen it used in ACS and I'm not sure why. I think most of the data is for enoxaparin, but I've never hear nor seen data to suggest that one LMWH is better or worse than another. At our hospital you just fill out the full dose cardiac heparin nomogram and check the "with bolus" box, and people look at you funny if you start talking LMWH. Of course, make sure he's not a huge bleeding risk for some reason.

If you get the OK for the cath lab, give your IIb/IIIa drug of choice - I've seen abciximab the most. If you're likely to go early conservative, then skip the IIb/IIIa inhibitor, as there is some mixed evidence about harm.

Skip the ACE, it will only reduce the amount of BB/CCB you can give, and the data is weak at best. Probably the same for an ARB, not sure though. If you happen to have a statin on the guy's tray anyway, go ahead and give it, but I wouldn't waste time with it.

BP and HR control would be nice as well, and probably sooner rather than later. For ACS I don't use orals. Metoprolol 5 mg iv q5 min x3 to get HR=60, but you should try to figure if the guy has asthma, and if so, maybe go with a CCB instead. I had this the other day in the ED (known asthmatic, actively wheezing, and questionable ACS) and I went with diltiazem 25 mg followed by 35 mg and it did so-so. If he's on a non-monitored bed, the nursing staff will probably need him moved to a monitored bed, which you'd be doing anyway.

If he has pain (doesn't sound like it) try some nitro. If that doesn't work, try some morphine, which will improve angina (maybe) and probably dyspnea as well.

You say he might be a drinker - holiday heart syndrome by any chance? Could this be other things - bad GERD triggering asthma? Might try a GI cocktail (viscous lidocaine and maalox po). GI bleed triggering an NSTEMI? Gotta keep the differential broad.

 

[Adcadet]

Which troponin are you using? I assume tnt given the <0.03 reference range thing. I've never heard of a tnt of 56. I never measure myoglobin either, dont know how specific/sensitive that is. Im assuming this isn't some weird systemic muscle injury (a bit odd that CKMB is still raised 48 hours after event, but with a troponin of 56.. who knows.) just a bog standard NSTEMI. Is he diabetic?

I too found it odd that you're talking about Trop (I vs T, don't care much) and all the CK's and myoglobin. I try to get CK-MBs on all my ACS patients as I've seen too many folks with renal insufficiency and mildly elevated trops (0.05, when NL is <0.03). The folks in the ED look at me funny when I check a CK-MB, but that's OK. On the other hand, somebody I trust said flat out that an elevated trop period is an elevated trop regardless of creatinine clearance. Regardless, I like to grab a CK-MB at least up front so I have a reference later on if need be to look for re-infarction later, with the thinking that trops stay too high too long to check on re-infarction. I'm guessing you use myoglobin in a similar way - IIRC it peaks the soonest of all the biomarkers. Given the myoglobin and CK-MB spike, I would have to think that there is acute stuff going on, and not just a single event two days ago. You officially have my attention.

OK, other stuff. This guy's a drinker. Found down? Aspiration pneumonitis +/- pneumonia? I'd think about a fluoroquinolone + clinda.