Clinico-Pathological Conference: Myocardial Infarction

1st
Clinico-pathological conference
Final Year MBBS
27th February, 2015
Myocardial
Presentation by infarction
1605- Abubakkar
Raheel
1622- Haider Ali
1606- Ahmed Arsalan
Long Case
• Muhammad Shareef, a 65 year old male patient from

Abbottabad, known case of Diabetes since last 12
years and Coronary Artery Disease for the last 2
years presented in King Abdullah Teaching Hospital
with the complaints of Chest pain and breathlessness
for the last 6 hours. Patient had an episode of
vomiting. He was conscious and well oriented.
Overall health state was weak and meagre.
Dept of Medicine
Frontier Medical and Dental College
Dept of Medicine
Dept of Medicine
History of Patient
• Name: Muhammad Shareef
• Sex: Male
• Age: 65 years
• Marital Status: Married
• Occupation: Retired Govt. servant
• Address: Abbottabad
• D.O.A: 20th February, 2015
• T.O.A: 9:30 am
• M.O.A: OPD
Dept of Medicine
Chief Complaints
• Chest pain – 6 hrs
• Shortness of Breath – 6 hrs
• Vomiting - 5 hrs
Dept of Medicine
History of Present illness
• Known case of Diabetes - 12 yrs &
Ischemic Heart Disease – 2 yrs
• Chest pain started 6 hrs back
• Sudden in onset
• Retrosternal
• Crushing in nature
• Radiating to left arm, back and neck
• Aggravated on exertion
Dept of Medicine
• Shortness of breath – 6hrs
• Sudden onset
• present at rest
• Vomiting – 5hrs
• 2 episodes of vomiting
• Vomitus was yellowish
Dept of Medicine
Associated symptoms:
• Moderate fever
• Sweating
• Dizziness
• Patient was completely conscious
• Palpitations
Dept of Medicine
• Systemic Inquiry
1. General
a. Reduced apetite
b. Sleep disturbed
c. Weakness
2. Respiration
Cough, wheezing and hemoptysis not
present
Dept of Medicine
• Alimentary system: Nausea & Vomiting
present
• Urinary system: No significant history
Dept of Medicine
History of Past illness
• Past Medical History
– Diabetes : 12 yrs
– IHD : 2 yrs
– HTN : Positive
– TB : Negative
– Asthma : Negative
• Past Surgical History
No significant past surgical history
Dept of Medicine
Family History
• Positive for IHD, HTN and DM
• 2 brothers died of MI
Dept of Medicine
Drug & treatment History
• Patient was taking anti diabetics and anti
hypertensive drugs
• Drug compliance was poor
• No other significant drug history
Dept of Medicine
Personal History
• Chronic Smoker
• No history of drinking
• Sedentary lifestyle
Dept of Medicine
Socio-economic History
• Satisfactory
Dept of Medicine
History based Differential Diagnosis
• Acute Myocardial Infarction
• Unstable Angina
• Pleurisy
• Pericarditis
• Pneumothorax
• Pulmonary embolism
• Reflex Esophagitis
Dept of Medicine
General Physical Examination
Patients general appearance
• Pale and anxious
Dept of Medicine
• Vitals
– B.P: 160/90mmHg in lying position
– Pulse: 115 b/m, regular, tachycardia
– Temp: 101 F
– Resp: 30/m
Dept of Medicine
• No Clubbing, pallor, splinter
hemorrhages koilonychias or leconichia
• Mild tobacco staining observed
• Xanthomas present on extensor
surface of hands
• Carotid pulse: thin
• JVP: Not raised
• Eyes: Anemia not present
Dept of Medicine
• Jaundice not present
• Dental hygiene good
• Carotid briut not audible
• No abnormality on fundoscopy
• No abnormality seen on thyroid
examination
• Lymph nodes not palpable
• Pedal and Sacral edema absent
• No other significant findings
Dept of Medicine
Systemic Examination
1. CVS Systemic Examination
a. Inspection:
• No Chest deformity
• No sternotomy or any other surgical
scar
b. Palpation:
• Apex beat: Lateralized from mid
clavicular line at 6th intercoastal spacece
due to LVH
Dept of Medicine
• Heave: well sustained (at apex)
• No left parasternal lift
c. Auscultation:
Mitral, Tricuspid, Aortic, Pulmonary
Dept of Medicine
• S1- Normal (Apex)
• S2- Audible (Left sternal edge)
• No added sounds
• No murmurs
Dept of Medicine
c. GIT:
• Liver not palpable
• Spleen not palpable
• Ascites not present
d. Respiration:
• Chest clear
• No tracheal shift
• No remarkable findings
Dept of Medicine
e. CNS:
No remarkable findings
Dept of Medicine
Examination based Differential Diagnosis
• Myocardial Infarction
• Unstable Angina
Dept of Medicine
Investigations - ECG
Dept of Medicine
Investigations
ECG:
Done within 25 mins of patient arrival

Findings:
• Rate: 78.9
• Rhythm: Sinus Rhythm
Dept of Medicine
Investigations
Leads showing ECG Changes:
• V1 to V6, AvL
• Changes include:
• ST Segment Elevation
• Q wave development
• Loss of R Wave
• T wave inversion
Dept of Medicine
Investigations
• Left Axis deviation seen by thumb rule on
Lead 1 and AvF
(For inferior wall MI, changes are seen in:

Leads 2, 3 and AvF)
Dept of Medicine
Investigations
 Cardiac biomarkers
• Trop T raised
• CK-MB raised
Chest Xray
• Cardiothoracic ratio increased showing LV
Dilatation
• Pulmonary edema not evident
Dept of Medicine
Investigations – Xray
Dept of Medicine
Investigations
Other Blood Tests
• ESR and CRP raised
Echocardiography could not be done due

to the non availablity of facility.
Dept of Medicine
Investigations based Diagnosis
Anterolateral ST Segment Elevation

Myocardial Infarction with Left Axis
Deviation
Dept of Medicine
Management
• Patient was immediately admitted in ICU. Within 10

mins, ECG was performed and based upon
diagnosis, following treatment was given.
• Oxygen + Cardiac rhythm monitoring
Dept of Medicine
Management
• Aspirin 300mg PO
• (Therapy should be continued indefinitely if there
are no side affects)
• Clopidogrel 600mg PO followed by 150mg daily for
1 week and 75mg daily thereafter.
• Streptokinase 1.5ml I.V in 100ml sol at 6ml/hr
• Inj Morphine
• Inj Metoclopromide I.V Stat
Dept of Medicine
Late Management
• Patient advised on the following:
• Lifestyle Modification:
• Lipid Lowering diet
• Cessation of Smoking
• Regular exercise
Dept of Medicine
Late Management
• Secondary Drug therapy:
• Aspirin
• B blocker
• Ace Inhibitor/ARB
• Statin
• Additional therapy for DM and HTN
Dept of Medicine
The patient was given Streptokinase (Thrombolysis)
within 8 hours of his arrival. He is still in the ICU
undergoing 24/7 observation and treatment. He
was advised angiography due to the unavailability of
the facility at the Hospital. We wish him a speedy
recovery. 
Dept of Medicine
What is MI ?
• Detection of rise and/or fall of cardiac biomarker
values (preferably cardiac troponin) with atleast one
of the following:
• Symptoms of Ischemia
• Significant ST segment-T wave changes or new LBBB
• Development of pathological Q waves
• Imaging evidence of new loss of viable myocardium
• Angiographic identification of Intra coronary
thrombus
Dept of Medicine
Types of MI
On the basis of ECG, there are two main types of MI
• STEMI (major coronary artery complete obstruction)
• Non-STEMI (Complete occlusion of a minor vessel or
partial occlusion of a major coronary vessel
Dept of Medicine
Arterial Supply of the Heart
Dept of Medicine
Dept of Medicine
There are two major arteries which supply the heart
• Left coronary artery
• Right coronary artery
1. Left Coronary Artery:

It is further divided into two main branches:
 LAD (I/V septum, Ant. Wall of LV and Apex)
 LCx (Lateral, Posterior and Inferior Walls)
Dept of Medicine
2. Right Coronary Artery
It supplies RA, RV and inferio-posterior part of LV
Branches include:
 PDA (supplies I/V septum inferior part) In 90%
individuals PDA is a branch of RCA. (Right Dominant
people)
In 10% individuals PDA is a branch of LCA (Left
Dominant)
Dept of Medicine
Arterial Supply of SA & AV Node
• SA Node: RCA in 60% individuals
• AV Node: RCA in 90% individuals
Clinical Significance:
• Proximal RCA occlusion may result in Sinus
Bradycardia and may also cause AV Nodal block
• Abrupt occlusion of RCA may lead to infarction of
inferior part of LV
Dept of Medicine
Conducting system of Heart
Dept of Medicine
Nerve Supply of Heart
• Adrenergic Nerves from the Cervical Sympathetic
chain supply atria and ventricles
• Parasympathetic: Vagus nerve
Dept of Medicine
Pathophysiology of MI
Atheromatous plaque formation
Interplaque haemorrhages
Exposure of Subendothelial
collagen fibers
Formation of micro thrombi vasospasm
Full blown thrombus
Dept of Medicine
Dept of Medicine
Dept of Medicine
• LCA Occlusion:
 LAD occlusion (40-50) leads to
Anterior wall infarction of LV
Anterior portion of ventricular septum
Apex
 LCx Occlusion 15-20%
Lateral wall of LV
Dept of Medicine
 RCA Occlusion (30-40%)
RCA occlusion leads to infarction of

• Posterior wall of RV
• Inferior wall of LV
• Posterior 1/3rd of I/V septum
Dept of Medicine
Clinical features
 Symptoms:
• Pain: Crushing, retrosternal chest pain radiating to
back, left arm, neck or jaw
• Anxiety and fear of impending death
• Nausea and Vomiting
• Breathlessness
• Diaphoresis
Dept of Medicine
Clinical features – Pain Areas
Dept of Medicine
Clinical features
• Signs
 Sympathetic activation:
- pallor
- sweating
- tachycardia
 Vagal activation:
-bradycardia
Dept of Medicine
Clinical features
 vomiting
• Signs of impaired myocardial function:
 Hypotention
 Narrow pulse pressure
 JVP may be raised
Dept of Medicine
Clinical features
 3rd heart sound
 Quiet 1st heart sound
 Diffuse apical impulse
 Lung crepitations
Dept of Medicine
Clinical features
• Signs of tissue damage
 fever
• Signs of complications e.g Mitral regurgitation,

pericarditis etc
Dept of Medicine
Clinical features
• Silent MI
 diabetic patients
 Older individuals
Dept of Medicine
Investigations
• ECG
• Cardiac biomarkers
• Chest X-Ray
• Echocardiography
• ESR & CRP
• Angiography
Dept of Medicine
Investigations
• ECG
It is central to confirming the diagnosis but may be
difficult to interpret if there is bundle branch block
or previous MI. so repeated ECGs are very
important.
Dept of Medicine
Investigations – Normal ECG
Dept of Medicine
Investigations – Normal ECG
Dept of Medicine
Earliest changes are seen in ST-segment
1. STEMI
• ST-segment elevation
• progressive loss of R wave .
• Development of Q wave .
• Resolution of ST-segment
• T-wave inversion
Dept of Medicine
2. NSTEMI
• St-segment depression
• T-wave changes
• Loss of R-wave
• Absence of Q-wave
Dept of Medicine
Investigations – ECG - STEMI
Dept of Medicine
 Significance of chest leads
 Antero-septal infarct
v1 ,v2,v3,v4
 Antero-lateral
v4,v5,v6 and AVL and 1
Dept of Medicine
 Inferior infarction
leads II , III and AvF
 Posterior wall infarction doesn’t cause ST elevation

or Q-waves in the standad leads but can be
diagnosed by the reciprocal changes that is st
depression and a tall R-wave and leads V1-V4.
Dept of Medicine
Cardiac Biomarkers
1. Troponins
2. Creatinine kinases
3. LDH
4. AST
5. Myoglobins
6. Most specific are troponins and CK-MB
Dept of Medicine
Cardiac Biomarkers
1. CK-MB
Rises in 4-6 hours and peaks a 12 hours and falls to
normal within 48-72 hours . It is very important.
For diagnosis of recurrent MI’s.
2. Troponins: Trop-T and trop-I are gold standards for

diagnosis of MI, Troponins rise in 4 to 6 hours and
remains elevated for 2 weeks
Dept of Medicine
Investigations- Chest Xray
• Chest Xray to determine cardiomegaly and
pulmonary edema
Dept of Medicine
Investigations - Echocardiography
• Useful for assessing ventricular function and

determining complications
Eg. Mural thrombus, cardiac rupture , VSD and

pericardial effusion etc
Dept of Medicine
Investigations - Other blood tests
1. ESR raised
2. Leucocytosis
3. CRP raised
Dept of Medicine
Management
Dept of Medicine
Management
Dept of Medicine
Drugs used in treatment of MI
1. Analgesics
- Opiates: Morphine Sulphate dimorphine
2. Anti-emetics: metoclopromide
3. Anti-thrombotic drugs
a. Anti platelets: Aspirin
- Clopidogrel
- Ticagrelor
- Gycoprotien 2b and 3a
receptor antagonists: Abciximab
Dept of Medicine
b. Anticoagulants :
– LMW Heparin, HMW Heparin,
pentasaccharide - fondaparinux
– Warfarin
Dept of Medicine
4. Anti anginal drugs
- Nitrates: GTN, isosorbide dinitrate
- B blockers: metoprolol and atenolol
5. Dihydropyridine CCBs:
- Nifedipine, amlodipine
6. Thrombolytics:
- Alteplase, streptokinase, retiplase, tenecteplase
Dept of Medicine
Invasive modalities used in the treatment of MI
• PCI (Percutaneous Intervention)
• CABG (Coronary Artery Bypass graft) Surgery
Dept of Medicine
Late Management of MI
Lifestyle modifications
Diet
Cessation of smoking
Weight control
Reguar exercise
Dept of Medicine
Late Management of MI- Sec prevention
• Anti platelet therapy
• B blockers
• Ace inhibitors
• Statins
• Additional therapy for diabetes and HTN control
• Mineralocorticoid receptor antagonist
• Devices: Implantable Cardiac Defibrillators
Dept of Medicine
Complications
• Arrythmias
• Bradycardia
• Acute Circulatory failure
• Pericarditis
Dept of Medicine
Complications - Mechanical
• Rupture of papillary muscle
• Rupture of I/V septum
• Rupture of ventricle which can lead to fatal cardiac
temponade
• Embolism
• Impaired ventricular function, remodeling and
ventricular aneurysm
Dept of Medicine
Prognosis
• If medical care is not provided, death occurs in
almost 1/4th of the cases. Half of the death occurs
within 24nhours of the onset of symptoms and
about 40% of all affected patients die within the
first month.
• Patients who reach the hospital and survive
have much better prognosis with a 28 day survival
of more than 85%. The prognosis of anterior
infarcts is worse as compared to inferior infarcts.
Dept of Medicine
Prognosis
OF THOSE WHO SURVIVE AN ACUTE ATTACK, MORE THAN

80% LIVE FOR A FURTHER YEAR. ABOUT 75% FOR 5 YEARS.
50% FOR 10 YEARS & 25% FOR 20 YEARS.
Dept of Medicine
Thankyou everyone 
Dept of Medicine
Frontier Medical and Dental Collegev

Clinico-Pathological Conference: Myocardial Infarction

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1st

• Muhammad Shareef, a 65 year old male patient from

Done within 25 mins of patient arrival

(For inferior wall MI, changes are seen in:

Echocardiography could not be done due

Anterolateral ST Segment Elevation

• Patient was immediately admitted in ICU. Within 10

• Oxygen + Cardiac rhythm monitoring

1. Left Coronary Artery:

Formation of micro thrombi vasospasm

Full blown thrombus

 RCA Occlusion (30-40%)

RCA occlusion leads to infarction of

• Signs of impaired myocardial function:

• Signs of complications e.g Mitral regurgitation,

 Posterior wall infarction doesn’t cause ST elevation

2. Troponins: Trop-T and trop-I are gold standards for

• Useful for assessing ventricular function and

Eg. Mural thrombus, cardiac rupture , VSD and

OF THOSE WHO SURVIVE AN ACUTE ATTACK, MORE THAN

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