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Afternoon Delight

A 60-year-old man presented with dull substernal chest pressure, diaphoresis, mild nausea, palpitations, and dyspnea. His medical history included diabetes and hypertension with no prior episodes of chest pain. Initial evaluation included vital signs and an EKG. The case emphasizes the pathophysiology of myocardial oxygen demand vs. supply and outlines initial interventions, including morphine, oxygen, nitrates, and the importance of timely PCI for STEMI. Key medications in discharge planning and long-term prevention strategies are also discussed.

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Afternoon Delight

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  1. Afternoon Delight PathoPhysiology Review July 29th, 2010

  2. Call from ED… • A 60-year-old man is coming in with chest pain

  3. Additional History • Dull substernal chest pressure for 1 hour with diaphoresis, mild nausea, palpitations, and dyspnea. • Denies prior history of similar chest pain, reflux, or heart failure symptoms. • PMH: DM, HTN • PSH: none • MEDs: Glipizide and HCTZ • ALL: none • SH: 15 pack year smoking history • FH: none

  4. Physical Exam T 37 ◦C BP 154/88(equal in both arms) HR 95 RR 20, 99%RA GEN:A+Ox3, mild distress HEENT: normal CV: RRR, normal heart sounds, grade 1/6 early systolic murmur at the upper left sternal border. No JVD PULM: CTAB ABD: soft NT, ND, +BS EXT: no edema

  5. EKG

  6. Initial Management?

  7. What Happened? Symptoms Discharge Diagnosis Medications Intervention

  8. Why? Symptoms Discharge Diagnosis Medications Intervention

  9. Angina occurs whenever myocardial oxygen demand exceeds supply Symptoms Demand Supply • O2 carrying capacity • PaO2 tension • Hemoglobin • O2 extraction • Coronary blood flow • Heart Rate • Systolic Blood pressure • Wall Tension • LVEDP/Preload • Wall thickness • Contractility 6:45 am

  10. Symptoms Demand o • Heart Rate • Systolic Blood pressure • Wall Tension • LVEDP/Preload • Wall thickness • Contractility 6:45 am Dis Mon 2008;54:671-689

  11. Symptoms Supply • O2 carrying capacity • PaO2 tension • Hemoglobin • Oxygen Extraction • Coronary blood flow 6:45 am • Atherosclerosis Oxygen content = (SaO2 x Hb x 1.34) + .003(PaO2) Coronary perfusion pressure = pressure gradient between the right atrial diastolic pressure and the aortic diastole pressure. Dis Mon 2008;54:671-689

  12. Symptoms • Oxygen extraction in the coronary circulation is almost maximal at rest. • The only significant mechanism available to the heart to increase oxygen consumption is to increase perfusion • In patients with progressive atherosclerotic narrowing of the epicardial vessels, an ischemic threshold occurs, and exercise beyond this threshold can produce: • abnormalities in diastolic and systolic ventricular function • electrocardiographic changes • chest pain 6:45 am

  13. STEMIs are caused by acute plaque rupture Symptoms 6:45 am N Engl J Med 2005;352:1685-95.

  14. Why? Symptoms Discharge Diagnosis Medications Intervention

  15. Diagnosis LCX 7:45 am

  16. Diagnosis 7:45 am N Engl J Med 2003;348:933-40.

  17. Diagnosis 7:45 am

  18. Why? Symptoms Discharge Diagnosis Medications Intervention

  19. Morphine • Oxygen • Nitrates • Aspirin • Beta-Blocker • Statin • Heparin/Lovenox Medications 8:05 am

  20. Angina occurs whenever myocardial oxygen demand exceeds supply Medications Demand Supply Morphine Oxygen • O2 carrying capacity • PaO2 tension • Hemoglobin • O2 extraction • Coronary blood flow • Heart Rate • Systolic Blood pressure • Wall Tension • LVEDP/Preload • Wall thickness • Contractility Nitrates βBlocker 8:05 am

  21. Medications Statins Aspirin Heparin 8:05 am

  22. Why? Symptoms Discharge Diagnosis Medications Intervention

  23. Primary PCI • lower short-term mortality rates • less nonfatal reinfarction • less hemorrhagic stroke than those treated by fibrinolysis • Door to Balloon Time • Mortality increases significantly with each 15-minute delay in the time between arrival and restoration of TIMI-3 flow (door to– TIMI-3 flow time) Intervention 9:10 am

  24. Intervention • Early clopidogrel may reduce CV death at 30days 9:10 am PeriproceduralGPIIb/IIIa improves CV outcomes Reduces risk of reinfarction

  25. Why? Symptoms Discharge Diagnosis Medications Intervention

  26. What meds to send home with? • Beta-blocker • Mortality benefit • Primary prevention of ventricular arrythmias • Aspirin • Clopidogrel • Statin • Ace-inhibitor • Should be given in first 24 hours of STEMI in setting of pulmonary congestion, anterior MI, EF<40% • +/- Aldosterone blocker • EPHESUS trial: for pts with EF<40%, HF, or diabetes on a stable regimen of beta-blocker and ACEi Discharge HD #5 Antman et al. Management of Patients With STEMI: Executive Summary JACC Vol. 44, No. 3, 2004 :671–719.

  27. Discharge HD #5 n engl j med 360 (21) 2009: 2237-40.

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