This document describes a case of a 63-year-old male patient admitted to the hospital with acute coronary syndrome involving the inferior wall of the heart. Key details include: - The patient presented with chest pain and was found to have an inferior wall myocardial infarction based on ECG and elevated cardiac enzymes. - An echocardiogram showed hypokinetic basal inferior and posterior walls. Coronary angiography revealed triple vessel coronary artery disease. - The patient underwent percutaneous coronary intervention with stent placement in the obtuse marginal and left circumflex arteries. - Medical therapy included aspirin, clopidogrel, statin, beta blocker, ACE inhibitor, and antianginal drugs to

1. Case on ACS – Inferior wall
Myocardial Infarction
By: Abhimanyu Parashar
5th Pharm.D
9/5/2013 1

2. ACS
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3. 9/5/2013 3

4. Myocardial infarction
0 Myocardial infarction (MI) or acute myocardial
infarction (AMI), commonly known as a heart attack
0 Typical symptoms of acute myocardial infarction:
1. Chest pain (typically radiating to the left arm or left side of the
neck)
2. shortness of breath
3. Nausea
4. Vomiting
5. Palpitations
6. Sweating
7. Anxiety
8. Fatigue
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5. Classification
0 There are two basic types of acute myocardial
infarction based on pathology:
1. Transmural:
0 Anterior
0 Posterior
0 Inferior
0 lateral
0 Septal
2. Subendocardial:
0 Involving a small area in the subendocardial wall of
the left ventricle, ventricular septum, or papillary
muscles
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6. 9/5/2013 6

7. 0 A 2007 consensus document classifies myocardial
infarction into five main types
1. Type 1 – Spontaneous myocardial infarction
2. Type 2 – Myocardial infarction secondary to
ischemia
3. Type 3 – Sudden unexpected cardiac death,
including cardiac arrest
4. Type 4 – Associated with coronary angioplasty or
stents
5. Type 5 – Myocardial infarction associated
with CABG
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8. 0 Age : 63 years
0 IP No. 1289064
0 Unit : Vikram Hospital (Dept. Cardiology)
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9. Reasons for admission
C/O:
0 Acute onset of Retro-sternal burning sensation
0 Mild sweating
0 Giddiness
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10. Patients History
0 PMHx: K/C/O Type 2 DM with Hypertension since 5
years
on Tab. Amace ( Amlodipine+ Enalpril) 1-0-0
Tab. Ecosprin (Aspirin 150 mg) 0-1-0
Tab. Dibizide M (Glipizide + Metformin)1-0-0
Tab. Melmet 500 (Metformin) mg 0-0-1
0 SHx: Smoker since 1 year
Alcoholic
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11. General examination
0 BP : 120/80 mmHg Pulse : 80
BPM
0 CVS: S1S2 +
0 ECG: Inferior Wall MI
0 Impression : ACS- IW.MI with T2DM and HTN
0 ADV : 2-D ECHO, Troponin-I, CKMB, CPK, RBG, Hb,
HCT, TC, S.Cr, Electrolytes, TSH.
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12. DAY 1
0 BP : 120/80 mmHg Pulse : 80 BPM
0 CVS :S1S2 +
0 2D ECHO: IHD, Hypo-kinetic basal Inferio-Posterior
wall
Ejection fraction: 50 %
Troponin I: +ve
Impression: ACS
0 At 9 PM : GC stable , No Angina/ Dyspnea
Vitals : Normal
0 ADV: CST
CBG (BB): 177 mg/dl
CBG (BL): 231 mg/dl
CBG (BD): 102 mg/dl
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13. 9/5/2013 13

14. Lab Reports
Biochemistry
CPK 170 (55-170 U/L)
CKMB 6.25 (0-3.38 ng/ml)
TROP-I 0.086 (0-0.035 ng/ml)
Glucose (R) 245 mg/dl
Urea 21 mg/dl
S.Cr 0.80 mg/dl
electrolytes
Sodium 132 mg/dl
Potassium 4.6 mg/dl
TSH 3.49 (0.465-4.68 micro IU/ml)
Hematology
Hb. 15
HCT 41.9 % (42 to 52 %)
MCV 87.7 fl (80 to 96 fl )
MCH 31.4 (27-33 pg /cell )
RBC 4.78 Lakhs Cell/cumm
PLT 2.36 Lakhs cell/cumm
WBC 12160 cell/cumm
Polymorphs 75.8 %
L 18
M 55
E 05
B 019/5/2013 14

15. Treatment chart
Drugs Dose R F
Inj. Heparin 5000 U IV Q8H
T. Aspirin 150 mg PO 0-1-0
T. Clopidogrel 75 mg PO 1-0-1
T. Trimetazidine MR 35 mg PO 1-0-1
T. Atorvastatin 40 mg PO 0-0-1
Syp. Cremalax (Na. Picosulfate) PO 0-0-1
T. Pantoprazole 40 mg PO 1-0-0
T. Restyl ( Alprazolam) 0.5 mg PO 0-0-1
T. Amace (Amlodipine + enalpril) 5+5 mg PO 1-0-0
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Inj. Actrapid if sliding scale > 200 mg/dl
T. Isosorbide Dinitrate 2.6 mg SL 1-1-0

16. DAY 2
0 BP : 130/80 mmHg Pulse: 88 BPM
0 CVS: S1S2 + , SSM + RS: Clear
0 ADV: CST, CAG counseling
At 5 PM: GC fair , No Angina/ Dyspnea
0 Troponin I: +ve
0 ADV: CST and CAG after RFT
RBG : 231 mg/dl
CBG (BB): 172 mg/dl
CBG (BL): 148 mg/dl
CBG (BD): 245 mg/dl
9/5/2013 16

17. Thrombolysis in Myocardial
Infarction
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18. Treatment chart
DRUGS Dose R F
Inj. Heparin 5000 U IV Q8H
T. Aspirin 150 mg PO 0-1-0
T. Clopidogrel 75 mg PO 1-0-1
T. Trimetazidine MR 35 mg PO 1-0-1
T. Atorvastatin 40 mg PO 0-0-1
Syp. Cremalax PO 0-0-1
T. Pantoprazole 40 mg PO 1-0-0
T. Restyl (Na. Picosulfate) 0.5 mg PO 0-0-1
T. Amace (Amlodipine + enalpril) 5+5 mg PO 1-0-0
T. Dibizide M (Glipizide + Metformin) 5+500 mg PO 1-0-0
T. Melmet (Metformin) 500 mg PO 0-1-1
T. Isosorbide Dinitrate 2.6 mg SL 1-1-0
Inj. Actrapid if sliding scale > 200 mg/dl 18

19. DAY 3
0 BP : 120/80mmHg Pulse : 72 BPM
0 CVS : S1S2 + RS: NVBS +
0 RBS: 172 mg/dl CBG (BB) : 180 mg/dl
0 ADV: CAG and CST
0 CAG report: Triple vessel disease
PTCA + stent of OM + LCX
0 Post CAG: TVD, No Angina/ Dyspnea
Vitals: Normal
0 ADV : CST , Counseling for PTCA + stent of OM and CLX
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20. 9/5/2013 20

21. Coronary Angiography Reports
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22. Coronary Angiography Reports9/5/2013 22

23. Treatment chart
DRUGS Dose R F
Inj. Heparin 5000 U IV Q8H
T. Aspirin 150 mg PO 0-1-0
T. Clopidogrel 75 mg PO 1-0-1
T. Trimetazidine MR 35 mg PO 1-0-1
T. Atorvastatin 40 mg PO 0-0-1
Syp. Cremalax (Na. Picosulfate) PO 0-0-1
T. Pantoprazole 40 mg PO 1-0-0
T. Restyl (Alprazolam) 0.5 mg PO 0-0-1
T. Amace (Amlodipine + Enalpril) 5=5 mg PO 1-0-0
T. Dibizide M (Glipizide + Metformin) 5+ 500 mg PO 1-0-0
T. Melmet (Metformin) 500 mg PO 0-1-1
T. Isosorbide Dinitrate 2.6 mg SL 1-1-0
Inj. Actrapid if sliding scale > 200 mg/dl9/5/2013 23

24. DAY 4
0 BP : 120/80 mmHg Pulse : 80 BPM
0 CVS : S1S2 +
0 Post CAG – TVD
0 NO Angina/ Dyspnea
0 ADV: CST , Discharge
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25. Treatment chart
DRUGS Dose R F
Inj. Heparin 5000 U IV Q8H
T. Aspirin 150 mg PO 0-1-0
T. Clopidogrel 75 mg PO 1-0-1
T. Trimetazidine MR 35 mg PO 1-0-1
T. Atorvastatin 40 mg PO 0-0-1
Syp. Cremalax (Na. Picosulfate) PO 0-0-1
T. Pantoprazole 40 mg PO 1-0-0
T. Restyl (Alprazolam) 0.5 mg PO 0-0-1
T. Amace (Amlodipine+Enalpril) 5+5 mg PO 1-0-0
T. Dibizide M (Glipizide + Metformin) 5+ 500 mg PO 1-0-0
T. Melmet (Metformin) 500 mg PO 0-1-1
T. Isosorbide Dinitrate 2.6 mg SL 1-1-0
Inj. Actrapid if sliding scale > 200 mg/dl 25

26. DRUG DOSE R F 1 2 3 4
Inj. Heparin 5000 U IV Q8H + + + _
T. Aspirin 150 mg PO 0-1-0 + + + +
T. Clopidogrel 75 mg PO 1-0-1 + + + +
T. Trimetazidine MR 35 mg PO 1-0-1 + + + +
T. Atorvastatin 40 mg PO 0-0-1 + + + +
T. Cremalax (Na. Picosulfate) PO 0-0-1 + + + +
T. Pantoprazole 40 mg PO 1-0-0 + + + +
T. Restyl (Alprazolam) 0.5 mg PO 0-0-1 + + + +
T. Amace (Amlodipine+Enalpril) 5 + 5 mg PO 1-0-0 + + + +
T. Dibizide M (Glipizide +
Metformin)
5+ 500mg PO 1-0-0 _ + + +
T. Melmet 500 mg PO 0-1-1 _ + + +
26
T. Isosorbide Dinitrate 2.6 mg SL 1-1-0 + + + +
Inj. Actrapid if sliding scale > 200
mg/dl
SC

27. Discharge Medication
DRUG DOSE R F COST/TAB COST/DAY
T. Aspirin 150 mg PO 0-1-0 0.80 Rs 0.80 Rs
T. Clopidogrel 75 mg PO 1-0-1 6.2 Rs 12.40 Rs
T. Trimetazidine MR 35 mg PO 1-0-1 7.5 Rs 15 Rs
T. Atorvastatin 40 mg PO 0-0-1 20 Rs 20 Rs
T. Amlopdipine+Enalpril 5+5 mg PO 1-0-0 4 Rs 8 Rs
T. Glipiizide +Metformin 5+500 mg PO 1-0-0 0.75 Rs 0.75 Rs
T. Metformin 500 mg PO 0-1-1 1.5 Rs 3 Rs
T. Pantoprazole 40 mg PO 0-0-1 6 Rs 6 Rs
T. Isosorbide Dinitrate 2.6 mg SL SOS __
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Total : 66 Rs/Day

28. PHARMACEUTICAL CARE
PLAN
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29. 9/5/2013 29
0 SUBJECTIVE EVIDENCE:
1. Retro-sternal burning
sensation
2. Mild sweating
3. Giddiness
0 OBJECTIVE EVIDENCE:
1. ECG: Inferior Wall MI
2. 2D ECHO: IHD, Hypo-
kinetic basal Inferio-
Posterior wall
3. Troponin I: +ve (0.086
ng/ml)
4. CKMB: (6.25 ng/ml)
5. CAG report: Triple vessel
disease

30. Final Diagnosis
ACS- Inferior wall MI with Triple Vessel
Diseases with Hypertension and Type
2 Diabetes Mellitus
9/5/2013 30

31. Goals of Treatment
0 Short term goals :
1. Initial evaluation & stabilization
2. Relief of ischemic chest discomfort
3. Efficient risk stratification
4. Focused cardiac care
5. Early restoration of blood flow to the infarct-related
artery to prevent infarct expansion.
6. Increase myocardial oxygen delivery
7. Prevention of death and other complications
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32. 0 Long term goals:
1. Prevent complications and recurrences.
2. Reduce mortality and improve quality of life
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33. Treatment Options
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For Hypertension For
IHD
For T2DM
• ACE- inhibitors –
Enalpril
• ARB’s –
Telmisartan
• CCB’s-
Dihydropyridine
Amlodipine
• Diuretics –
Furosemide
• Beta Blockers –
Atenolol
Metoprolol
• Anti-Platelet agents –
Aspirin , clopidigrel
• Anti-anginal –
Trimetazidine
Nicorandil
Ranolazine
• Anti- Hyperlipedimic
agents –
Atrovastatin
• Vasodilators-
Nitrates
•Sulfonylureas –
Glipizide
•Biguanides –
Metformin
•Insulin

34. 9/5/2013 34

35. 9/5/2013 35
0 Signs and symptoms
were reduced by day 2
0 Lipid profile not done
GOALS ACHIEVED Problems Identified

36. Monitoring Parameters
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0 Disease related :
1. Blood Pressure
2. ECG
3. 2D-ECHO
4. Blood Glucose levels
5. Hb A1c
6. Lipid Profile
0 Drug related :
1. Platelets count
2. Blood pressure

37. Patient Counseling
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38. About Disease
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39. 9/5/2013 39

40. About PTCA
0 Advantages:
1. It can be done under local anesthesia.
2. The procedure is faster. Recovery period is shorter
and less painful
3. The procedure does not leave a noticeable scar
4. It is a useful procedure for patients unwilling or
unable to undergo surgery.
5. A repeat procedure, if required, is easier to perform
than a repeat bypass surgery.
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41. 0 Disadvantages:
1. Coronary angioplasty can be used only if one or two
arteries are affected
2. It cannot be used in arteries that cannot be reached
by the catheter
3. It may not be effective against very hard
atherosclerotic plaques.
4. Restenosis may occur, especially if a stent is not
placed during the procedure
9/5/2013 41

42. About Medications
0 Name and purpose
0 Dose and frequency
0 Medication adherence
0 Possible adverse effects
0 Missed dose
9/5/2013 42

43. About life style modification
Thursday, September
05, 2013
43
0 Healthy life style with daily exercise
(the ADA recommends 150 min/week (distributed over at
least 3 days) of aerobic physical activity)
0 Self-Monitoring of Blood Glucose
0 Nutritional recommendations
0 Driving: no driving for 1month. after Ml.
0 Flying: most airlines will not carry passengers for 2wk.
post Ml and then only if able to climb 1 flight of stairs
without difficulty

44. 0 Physical activity: advise gradual increase in activity
1. 2wk. after Ml stroll in garden or street
2. 4wk. after Ml walk @ ½ mile/d.
3. 4 to 6wk. after Ml increase to 2 miles/d. by 6wk.
4. From 6wk increase the speed of walking; aim 2 miles in
<30min.
0 Sexual activity: resume after 6wk
0 Return to work :
1. Sedentary workers 4-6wk. after uncomplicated Ml
2. Light manual workers 6-8wk. after uncomplicated Ml
3. Heavy manual workers 3months after uncomplicated Ml
9/5/2013 44

45. 0 Monitoring health: continue regular reviews at least
annually for lifelong. Check for symptoms and signs of
cardiac dysfunction (breathlessness, palpitations,
angina).
0 Secondary prevention
0 Smoking cessation
0 Hypertension ,Check BP and refer physician if >140/90
0 Alcohol withdrawl.
9/5/2013 45

46. Thursday, September
05, 2013
46
Fat 20–35% of total caloric intake
Saturated fat < 7% of total calories
<200 mg/day of dietary cholesterol
Two or more servings of fish/week provide -3
polyunsaturated fatty acids
Carbohydrate 45–65% of total caloric intake (low-carbohydrate diets
are not recommended)
Sucrose-containing foods may be consumed with
adjustments in insulin dose
Protein 10–35% of total caloric intake (high-protein diets are
not recommended)
Other components Fiber-containing foods may reduce postprandial
glucose excursions
Nonnutrient sweeteners

47. THANK U
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