anterior mi

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Presentation Description

acute anterior myocardial infarction with conduction defect.

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By: ahmedhafez2030 (13 month(s) ago)

لا حرمنا الله من حلمك حالت شيقه ننتظر مزيدك بوركت يمينك

 

By: ahmedhafez2030 (13 month(s) ago)

لا حرمنا الله من حلمك حالت شيقه ننتظر مزيدك بوركت يمينك

 

By: ahmedhafez2030 (13 month(s) ago)

لا حرمنا الله من حلمك حالت شيقه ننتظر مزيدك بوركت يمينك

 

By: ahmedhafez2030 (13 month(s) ago)

لا حرمنا الله من حلمك حالت شيقه ننتظر مزيدك بوركت يمينك

 

By: ahmedhafez2030 (13 month(s) ago)

لا حرمنا الله من حلمك حالت شيقه ننتظر مزيدك بوركت يمينك

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Presentation Transcript

CASE PRESENTATION : 

CASE PRESENTATION DR. JAWED

BIODATA : 

BIODATA Name: ABC Age: 65 years Sex: Male Address:

Presenting complain : 

Presenting complain Chest Pain since 4 hours

History of presenting illness : 

History of presenting illness 65 years old male presented in Emergency room with history of retrosternal chest pain since 4 hours, sudden, severe, prolong, burning, radiating to left shoulder, associated with sweating and vomiting .

History of Presenting illness : 

History of Presenting illness Pain not increase by inspiration or changing in position. No history of shortness of breath, no palpitation, no history of fever, no cough or hemoptysis, no history of fall down or any trauma.

Review of systems : 

Review of systems General: No loss of weight No change in appetite No malaise or weakness No sleep disturbanceGIT: No abdominal pain No Diarrhea or constipation No haematamesis or melana

Review of systems : 

Review of systems Respiratory system: No difficulty in breathing No coughGenito urinary: No burning micturation No haematuriaCNS: No fits No weakness

PAST HISTORY : 

PAST HISTORY Hypertensive since 15 years, using regular medication Diabetic since 12 years Never admitted in hospital before. No history of any major surgery

Slide 9: 

No complain of peripheral numbness No dizziness on standing or walking, no history of increase sweating after meals, no tachycardia, sweating or tremor during fasting, no visual disturbance No diarrhea or any other symptom.

Family History : 

Family History Died of heart problem cause not known

PERSONAL HISTORY : 

PERSONAL HISTORY Non smoker Bowel and dietary habits normal.

Drug history : 

Drug history Enalapril 10mg daily Glibenclamide 10 mg daily

Summary : 

Summary 65 years old male diabetic, HTNsive with history of retrosternal chest pain since 4 hours, prolong, severe, burning, associated with sweating and vomiting.

Slide 14: 

Peptic ulcer disease Pulmonary embolism

Examination : 

Examination Old aged male with average height and built lying on bed conscious and oriented. Pulse: 106 b/ min regular BP: 130/ 80 mmHg Temperature: 37.0

Examination : 

Examination No pallor or jaundice No clubbing or splinter hemorrhages JVP not raised No carotid bruit No neck swelling No palpable lymph nodes

Examination : 

Examination Pulses equally palpable on both sides, normal volume No radio femoral delay No lower limb or sacral edema No rashes

Cardiovascular examination : 

Cardiovascular examination Apex beat in 5th intercostal space at mid clavicular line, non sustained. No thrill or heave S1 and S2 with normal intensity. No gallop or murmur

Respiratory system : 

Respiratory system Chest bilaterally symmetrical moving with respiration. Vesicular breathing No crepits or ronchi

Gastrointestinal system : 

Gastrointestinal system No hepatosplenomegaly Central Nervous System Normal sensory and motor exam Fundoscopy: Normal fundus exam

SUMMARY : 

SUMMARY 65 years old male diabetic, HTN with history of retrosternal chest pain since 4 hours severe with sweating had normal pulse and blood pressure and no significant exam finding.

Differential diagnosis : 

Differential diagnosis Myocardial infarction Aortic dissection

Differential diagnosis : 

Differential diagnosis Aortic dissection Myocardial infarction

ELECTROCARDIOGRAM : 

ELECTROCARDIOGRAM

ELECTROCARDIOGRAM : 

ELECTROCARDIOGRAM

ELECTROCARDIOGRAM : 

ELECTROCARDIOGRAM

CHEST X-RAY : 

CHEST X-RAY Normal heart shadow No pulmonary congestion

Investigation : 

Investigation Cardiac enzymes: CK: 276– 4685—1941 LDH: 413– 2653 AST: 40-- 409 Troponin T: 10.66 . Creatinine: 102 Na: 134 K: 4.1

ECHOCARDIOGRAPHY : 

ECHOCARDIOGRAPHY CONCENTERIC HYPERTROPHY OF LV HYPOKINETIC SEPTUM AND ANTERIOR WALL EF: 60% NORMAL VALVES MORPHOLOGY NORMAL RIGHT SIDE NO PERICARDIAL EFFUSION

ACUTE ANTERIOR WALL ST ELEVATION MYOCARDIAL INFARCTION with RBBB : 

ACUTE ANTERIOR WALL ST ELEVATION MYOCARDIAL INFARCTION with RBBB

Slide 31: 

TRAETMENT Thrombolysis Anticoagulant ACE Inhibitors B-Blockers Statins NTG

MI WITH CONDUCTION DEFECTS : 

MI WITH CONDUCTION DEFECTS Anterior MI — Serious conduction disturbances more commonly occur with anteroseptal MI, and the degree of arrhythmic complications is usually directly related to the extent of infarction. Bundle branch block — The presence of fascicular or bundle branch block (BBB) during an acute MI is associated with an increase in in-hospital and long-term mortality

Slide 33: 

In contrast to CHB, which is almost always a new finding due to the MI, BBB often precedes the MI. In the HERO-2 trial, BBB was present in 5.1 percent of initial ECGs, but new BBB developed in only 0.9 percent of patients on a second ECG taken 60 minutes later

Slide 34: 

Chronic and new conduction abnormalities may both predict poorer outcomes, but for different reasons. The former due to more extensive underlying cardiac disease and the latter due to the association with larger infarctions.

Slide 35: 

In the NRMI-2 review, 12.9 percent of almost 300,000 patients had LBBB or RBBB. The unadjusted in-hospital mortality was 22.6 and 23.0 percent with LBBB and RBBB, respectively, compared to 13.1 percent in patients with no BBB.

Slide 36: 

In an analysis of 26,0003 North American patients entered into the GUSTO-I trial of thrombolytic therapy, the in-hospital mortality was 18 versus 11 percent with and without a BBB Mortality was higher when the BBB was persistent (20 percent versus 12 and 8 percent in the 24 percent of patients who had partial or complete resolution of the BBB, respectively).

Slide 37: 

In the PAMI trials; LBBB was present in 1.6 percent and RBBB in 3.1 percent. In-hospital mortality was 14.6, 7.4, and 2.8 percent in patients with LBBB, RBBB, and no BBB, respectively

Slide 38: 

In Hero trial 30-day mortality was significantly increased only in patients with RBBB at baseline and an anterior MI (odds ratio 2.48) and in those with new LBBB (odds ratio 2.97) or new RBBB with an anterior MI (odds ratio 3.84). New bifascicular block (RBBB plus either left anterior or left posterior fascicular block) was associated with a 31 percent risk of CHB

TIMI RISK SCORE : 

TIMI RISK SCORE AGE 65 ---------- 2 HEART RATE 106 ---------- 2 ANTERIOR MI ---------- 1 DM + HTN ---------- 1 TIME OF TREATMENT ---------- 1 TOTAL ---------------------- 7

Slide 41: 

THANK YOU

CONCLUSION : 

CONCLUSION The presence of a RBBB in the setting of an acute myocardial infarction is associated with a significant increase in mortality, even when thrombolytic therapy has been administered.

Cardiac conditions that can cause RBBB include the following : 

Cardiac conditions that can cause RBBB include the following Chronically increased right ventricular pressure, as in corpulmonale, which may also be associated with electrocardiographic findings of right ventricular hypertrophy. A sudden increase in right ventricular pressure with stretch, as in pulmonary embolism. Myocardial ischemia, infarction, or inflammation (as in myocarditis). Other causes include hypertension, cardiomyopathies, and congenital heart disease. RBBB can also result from idiopathic progressive cardiac conduction disease