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    Acute Coronary Syndrome

    MED II 2013

    Case Discussion

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    ACS case discussionObjectives

    Understand difference of mechanisms andoutcomes of myocardial ischemia @ special clinical

    scenarios

    Underscore co-existence of multiple vascular bedinvolvement by athero-thrombosis

    Recite the basic patho-biologic elements &

    expression spectrum of Acute coronary syndromeExplore bench-bedside implementation of

    diagnostic and therapeutic strategies in ACS.

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    Case Discussion

    Clinical History

    50 yr old male, chronic heavy smoker.

    History of labile hypertension.

    Leads sedentary life style

    Has family history of CHD (father had Myocardialinfarction at age 56)

    He has been asymptomatic except for Brief and mild

    chest pain , during brisk walk one day before

    Presented to Emergency department withAcute and

    severe chest pain lasting 10 min

    EKG: ST elevation, normalized after 10 minutes

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    Case Discussion

    Patient gives history of Negative routine Myocardial

    Perfusion Imaging (Thallium) stress test 3 months ago.

    At that time, he had negative physical examination

    except for a soft femoral artery bruit and BP 130/80;

    Ankle-Brachial index 0.75

    LDL was 178,CRP was 4.2 mg/dL (Normal:

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    Case Discussion (Contd.)

    At this stage the patient became pain free;Troponin T was 0.08(Nl

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    Clinical Pathway A

    Case Discussion

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    Patient was admitted to hospital18 hours after admission, the patient underwent

    cardiac catheterization. He had been loadedwith Anti-platelet (Clopidogrel), & was given an

    infusion of GPIIB-IIIA Blocker (Tirofiban), inaddition to Aspirin and Heparin.

    He was found to have :

    - 90% mid left anterior descending (LAD),- The lesion in the LAD had ulcerated,roughened angiographic appearance.

    -Normal RCA & Circumflex.

    Case Discussion

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    24 Hr. @

    Hep,antiplatele

    t includingIIb/IIIa and

    Plavix/Asp.

    Coronary Angiography

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    Clinical Pathway B

    Case Discussion

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    In Emergency room, Patient was feeling

    well, became pain free and declined

    admission to hospital. He was discharged on Aspirin and

    Cholesterol lowering Medications

    Case Discussion

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    One day later he experienced severe chest

    pain which persisted for >20 minutes.

    He was brought to Emergency department

    with severe pain, and profuse sweating. The

    following EKG was recorded

    Case Discussion

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    ST-Segment Elevation Myocardial Infarction

    (STEMI)

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    Patient was cleared for Pharmacologicintervention

    Intravenous Tenecteplase was administeredintravenously with initial partial improvement of

    pain and diminishing ST elevation! Pain quickly returned with re-elevation of ST

    segments

    Case Discussion