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A Pathophysiology- BN607 > Case study: Mike (MI) > Flashcards

Case study: Mike (MI) Flashcards

1
Q

Who is Mike and what is his initial scenario

A

39 years old and works full-time as a forestry contractor. He lives with his partner and developed chest pain one night that he thought was indigestion.

Over a few hours his symptoms worsened and emergency services were called and Mike M was brought to a local hospital. At the time of his admission to this hospital, Mike was pallor, sweating and in severe pain. While being transported via ambulance, Mike was given aspirin and nitroglycerine (GTN) with no effect from either, and an ECG showed S-T elevation.

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1
Q

What was mikes symptoms leading up to hospital admission?

A

Chest pains starting in the afternoon- Thought it was indigestion. Pain persisted. Pain in sternum region (central).

8/10 CP

Morphine no effect

Diaphoresis

Chills

Tingling in L) arm/ hand. “Said it felt like an overused muscle).

Pallor. Specifically in peripheral regions (hands and legs)

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2
Q

What are risk factors for an MI?

A

Non-modifable
- Older adult age
- Male sex
- Family hx/genetics

Modifable
- Hypercholesterolemia
- Hypertension
- Obesity
- Physical inactivity
- Hyperglycemia/diabetes
- Tobacco use
- Hyperlipidemia

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3
Q

What were Mikes risk factors?

A
  • Genetics “Never been a male who lived past 60”. All had heart problems with the same artery
  • Smokes “Wouldn’t be a packet a day”
  • Male sex

Doesnt think its because hes “unfit” says hes fit.

Blood tests post MI show
- Hyperlipidemia/ hypercholesterolemia
- Atherosclerosis

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4
Q

What are general symptoms of an MI?

A
  • Diaphoresis
  • Pallor/ Pale perhiers
  • CP or discomfort
  • SOB
  • Anxiety
  • Pain in shoulder, neck, arm or jaw
  • Nausea/vomiting
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5
Q

What medications had no effect on Mike ambulance service

A

Aspirin, GTN spray and morphine

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6
Q

What are signs (Not symptoms) Mike was having an MI?

A

S-T elevation on ECG
No relief with medication- aspirin, GTN, morphine

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7
Q

What is an MI?

A

A myocardial infarction (MI) occurs when there is sustained myocardial ischemia due to blockage of a coronary artery

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8
Q

What is the most common cause of Ischemia associated MI?

A

A thrombus forms after an atheroscerotic plaque in the coronary artery ruptures

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9
Q

What does prolonged ischemia lead to?

A

Irreversible hypoxic damage to the affected section of the heart wall, resulting in myocyte necrosis.

Ischemic injury also affects areas surrounding the zone of necrosis (infarct area).

As myocytes become necrotic, their cell membrane (sarcolemma) breaks down and cellular contents are leached into the surrounding body fluids, including blood.

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10
Q

What is myocardial stunning?

A

Temporary loss of contractility lasting hours to days after reperfusion

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11
Q

What is myocardial hibernation?

A

Prolonged loss of contractility when there is sustained ischemia

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12
Q

What is a STEMI?

A

Stands for: ST-segment elevation myocardial infarction

Full thickness necrosis
S-T segment elevation on ECG

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12
Q

What is myocardial remodeling?

A

Permanent loss of contractility with cellular hypertrophy

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13
Q

What is a NSTEMI?

A

Stands for: non-ST-elevation myocardial infarction

Partial thickness necrosis (Subendocardial)
NO S-T elevation on ECG

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14
Q

What kind of MI did mike most likley have?

A

STEMI

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15
Q

What was mikes BP and HR upon admission?

A

His blood pressure (BP) was 107/78 mmHg

heart rate (HR) was 80 bpm.

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16
Q

Which laboratory tests would you expect for a routine chest pain or suspected MI admission?

A
  • FBC
  • Cardiac enzymes
  • BGL
  • Urea and electrolytes
  • Thyroid function test
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17
Q

Which investigations would you expect for a routine chest pain or suspected MI admission?

A
  • Angiogram
  • Chest xray
  • ECG
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18
Q

What does an ECG measure?

A

Measures the electrical activity of the heart.

Ten electrodes are placed on the skin to measure twelve (12) leads (graphical representation of electrical activity) which record cardiac depolarization and repolarization throughout the cardiac cycle from different directions.

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19
Q

What does the P wave represent?

A

Atrial depolarization

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20
Q

What does the QRS complex represent

A

Ventricular depolarization + atrial repolarization (repolarization wave is overshadowed by the depolarization wave

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21
Q

What does the T wave represent?

A

Ventricular repolarization

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22
Q

What are some key ECG changes that might be seen in association with MI

A
  • Peaked T waves
  • Inverted T waves
  • S-T segment depression
  • S-T segment elevation
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23
Q

What does peaked T waves suggest?

A

Suggests ischemia in the endocardium.

24
Q

What does Inverted T waves suggest?

A

Suggests ischemia in the epicardium. causing the wave of repolarisation to travel outwards.

25
Q

What does S-T segment depression suggest?

A

Suggests subendocardial ischemia or infarction. Also seen in leads opposite an infarcted area.

26
Q

What does S-T segment elevation suggest?

A

Suggests transmural infarction.

27
Q

what did Mikes ECG show?

A

S-T elevation and S-T depression a

Changes in the S-T segment reflect damage to the ventricular walls of the heart.

28
Q

When testing Cardiac enzymes, what enzymes are you testing for?

A
  • Troponin T
  • Troponin I
  • Myoglobin
  • CK-MB
  • CK
  • LDH
29
Q

What is Troponin T

A

Troponin T is a contractile protein that is only released from myocytes when necrosis has occurred, and thus it is highly sensitive, and specific, to cardiac muscle cell damage.

Troponin levels may not be detectable for up to six hours after the onset of myocardial cell injury.

It is usually measured at presentation and again 10-12 hours after the onset of symptoms or presentation.

30
Q

What did mikes blood tests show?

A

Very high troponin (9)
Higher triglycerides
Low HDL

31
Q

After the ECG confirmed mike had an MI, what medications did they give him?

A

He was administered thrombolytic drugs
(tenecteplase & enoxaparin)

32
Q

What happened after Mike was given thrombolysis

A

Went into ventricular fibrillation (VF) cardiac arrest.

Was resuscitated with AED.

Asked “Sorry did I fall asleep”

Defibrillation returned a normal sinus rhythm, however, Mike then developed atrial fibrillation.

33
Q

What medications did they give Mike at base/regional hospital

A

Mike was administered GTN, metoprolol, tirofiban & clopidogrel and was then subsequently transferred to the closest tertiary hospital.

34
Q

What occured at the base/regional hospital?

A

Mike was experiencing atrial fibrillation and shortly thereafter developed chest pain, with some pain in his left limb.

ECG showed acute MI

35
Q

What is the Immediate management of acute MI?

A
  • Decrease heart workload
  • Increase oxygen delivery to body tissues
  • Re-perfuse the heart wall

MONA, thrombolysis, bloods (Check troponin/ electrolytes), ECG, electrolytes like K+ may need to be given

In addition to observations and an ECG, initial management involves symptom control

36
Q

What does MONA stand for?

A

Morphine
Oxygen (O2)
Nitroglycerin
Aspirin

37
Q

Why give morphine with an acute MI?

A

To relieve chest pain if chest pain doesn’t resolve with sublingual or I.V. nitroglycerin.

38
Q

Why give O2 with an acute MI?

A

Given if the patient’s O2 saturation level is below 92% to ensure adequate oxygen delivery.

39
Q

Why give Nitroglycerin with an acute MI?

A

Given to reduce chest pain. Is a potent vasodilator, decreases myocardial oxygen consumption and cardiac workload.

40
Q

Why give Aspirin with an acute MI?

A

Given if not already taken. Slows platelet aggregation, reducing the risk of further occlusion or re-occlusion of the coronary artery or a recurrent ischemic event.

41
Q

What is the most ideal therapy for reperfusion therapy?

A

Primary percutaneous coronary intervention (PCI), if performed in a timely fashion, is the reperfusion therapy of choice in patients who have had an acute S-T elevation myocardial infarction (STEMI). If angiography is not available, thrombolysis is likely to occur first.

42
Q

At the first hospital Mike received thrombolysis. What medications did they give him?

A

Enoxaparin (Clexane)
Tenecteplase

43
Q

What is Enoxaparin (Clexane)

A

Enoxaparin (Clexane): a low molecular weight heparin that helps prevent the original arterial clot from expanding and allows it to break down, opening up the vessel and inhibiting new clot formation. Clexane is administered as a subcutaneous injection, as well as an IV bolus in the acute setting.

44
Q

What is Tenecteplase

A

Tenecteplase: a fibrinolytic which binds to fibrin and converts plasminogen into plasmin, which then degrades fibrin. It is administered intravenously and should be given as soon as possible after MI, if primary PCI is not available.

45
Q

What did mike received after transfer to the tertiary hospital?

A

Mike underwent an angiogram followed by PCI (angioplasty with stent).

46
Q

What is a Percutaneous coronary intervention (PCI)

A

Percutaneous coronary intervention (PCI) involves the use of coronary angiograms to visualize and assess the damage associated with coronary ischemia.

Once the problem is located angioplasty can be performed to open up the affected vessel(s).

47
Q

What is an Angiogram

A

An angiogram is performed by injecting a contrast agent into the bloodstream, which makes the blood vessels surrounding the heart visible on an x-ray.

  • Local anesthesia
  • Used to do the femoral artery, but more recently use radial.
  • Puncture the artery, small flexible wire inside the artery, to guide in a dilator and sheath.
  • Once sheath is introduced into system, provides a route so they can put wires and longer catheters.
  • Through the catheters they put contrast material.
48
Q

What is the angiography patient care?

A
  • Prepare for the procedure. Write gear. Shaved. Safe and comfortable. Baseline obs. Pain managment.
  • Coronary care unit- cath lab- ward.
  • Continuous cardiac monitoring. Still have infusions running. Wrist puncture (Nurse assessing wound). Puncture would have a tight band around it with a balloon that has pressure that will gradually release. Comfort. Sometimes have a stent related discomfort.
49
Q

What is an angioplasty with stent?

A

This is a technique used to widen a narrowed or obstructed artery.

In the procedure, a collapsed metal tube (stent) surrounding a collapsed balloon is passed into the vascular system using a guide wire (catheter).

The balloon is positioned in the narrowed area and then inflated.

This squashes the deposits causing the narrowing and expands the stent, thus opening the blood vessel. The balloon is then deflated and removed, while the stent remains to keep the artery open, thus allowing the return of normal blood flow.

50
Q

What are common discharge management medications?

A
  • Aspirin
  • Anti-coagulants
  • Beta blockers
  • Nitroglycerine
  • Cholesterol lowering medications
51
Q

What is Aspirin (acetylsalicylic acid)?

A

A nonsteroidal anti-inflammatory drug (NSAID) which prevents platelet aggregation, therefore helping to prevent blood clotting.

52
Q

What is Clopidogrel?

A

Inhibits platelet activation and aggregation; often used in combination with aspirin to prevent thrombosis after angioplasty.

53
Q

What is Glyceryl trinitrate (GTN) spray

A

Glyceryl trinitrate (GTN) spray: relaxes smooth muscle (potent vasodilator) & decreases cardiac workload; best used as required for angina or MI.

54
Q

What is metoprolol?

A

Metoprolol: β-adrenoceptor antagonist (beta blocker) which reduces heart rate (HR), cardiac output (CO) and blood pressure (BP) through inhibition of catecholamines

55
Q

What is Simvastatin?

A

Simvastatin: inhibits cholesterol synthesis to lower cholesterol

56
Q

Why is it recommended to take Simvastatin in the evening?

A

Because cholesterol synthesis occurs mostly at night

57
Q

What are post MI managment advice?

A
  • Getting cholesterol tested after 3 months
  • Smoking cessation
  • Cardiac rehab classes
  • Dietary changes
58
Q

What diet is recommended?

A

Dietary changes include a low-fat, low-salt diet with plenty of fruit and vegetables.

Are we meeting nutrient needs

A Pathophysiology- BN607 (28 decks)

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