Things not to miss - Acute MI

A 54 years old male patient, known to have GORD for many years presented with burning chest pain. The pain was persistent. There was no radiation to the arm. He had sweating and nausea. There was no shortness of breath.
He is a smoker.

He has never tested his blood sugar or lipid profile.

On examination, the patient is ill and sweaty. The pulse rate is 92/min. Blood pressure is 150/100mmHg. There are no murmurs. Lungs are clear.

What are you going to do?

This is a very common clinical scenario. Nearly half of the patients you encounter will admit that they have ’Gastritis’. The majority who present with chest pain believe that the pain is due to gastritis.

So the clinical problem is differentiating ischemic chest pain from gastritis.

What features will suggest that the pain is ischemic?

You know what the features are. I’ll highlight only a few points.

In most MIs the pain is tightening. But we have seen patients with burning pain coming with MI. Sometimes it’s the pain of gastritis which precipitates MI!

Patients never shout or run around the ward with pain. They stay still holding the chest.

Jaw tightness is a very reliable feature of MI. Always ask.

Worsening of pain with exertion and recent history of angina is suggestive.

If the duration of the pain is unusually prolonged, say more than 1 hour, and the patient is quite well, its more likely non-ischemic. Because if the ischemia lasts for such a prolonged duration it should result in a large infarction. The patient will really be ill.

How are you going to manage?

ABC!


Once you are happy with ABC! do the following.

ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG, ECG!

We’ll discuss ECGs in patients with chest pain on a different day.


  • If you have an ECG machine at the ward, don’t wait for the ECG technician to come.
  • One ECG is almost equal to having no ECG if there are no ST elevations.
  • Repeat ECGs frequently! 
  • During your ward rounds in the morning and evening, make sure to repeat ECGs of all patients with acute coronary syndromes!
  • Any NSTEMI can become a STEMI while in the ward!


1. Aspirin - What’s the dose, how to administer?

2. Clopidogrel - What’s the dose?

3. Atorvastatin - What’s the dose?

4. GTN - You can give sublingual GTN for pain relief. If the blood pressure is high IV GTN can also be given. Ask your senior!

5. Morphine - Don’t hesitate. Don’t give pediatric doses!

6. If you gave morphine - give an antiemetic parenterally.

What else?

Did you check the blood sugar?

What are the types of acute coronary syndromes?
Read the differences and how to diagnose each.

Unstable angina
Non ST elevation MI
ST elevation MI

If the diagnosis is unstable angina or Non-STEMI, you have to anticoagulant the patient.

What we usually give is Enoxaparin 1mg/kg twice a day.
It’s a very safe drug in the absence of active bleeding. So don’t be afraid to prescribe.

If the diagnosis is STEMI You have to perform thrombolysis!

Really?

No!

The best management is percutaneous coronary intervention, which is now available in many major hospitals, including Kandy.

If the PCI facility is not available, you have to perform thrombolysis.

Thrombolysis with what?

Streptokinase? well, if your answer is that, you are an ancient man!

What newer drugs are available for thrombolysis?
Are they available in Sri Lanka? Yes! so. read!

On another day, we will discuss some more about the management of acute coronary syndromes.

But if you can't wait,

Read about
1. Complications of acute coronary syndromes
2. Indications/ contraindication of thrombolysis and PCI
3. Complications of thrombolysis
4. What other drugs are indicated for patients with MI?
5. What things should you do at the time of discharge?

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