Concluded Case

80 yrs old male,brought by relatives, in drowsy state, h/o chest pain and vomiting since last evening. BP 70 systolic. spo2 80%. CVS pan systolic murmer+ RS bil crepts heard ECG attached. patient is taken on invasive ventilation. Hb 8, sr creat 3.2, urea 80, BSL 86, trop T positive.

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ECG shoes ST segment elevation in lead II and III with reciprocal changes in lead I, along with Trop T positive It indicate hyperacute myocardial infarction Along with that he has pan systolic murmur indicating mitral/ tricuspid regurgitation Congestive cardiac failure Acute renal failure associated with hypotension, hypoxia He needs urgent ionotropic support to improve blood pressure to maintain perfusion of vital organs however ionotropic support will cause vasoconstriction of coronary artery and further aggravate ischaemia, therefore he needs, in addition, intra arterial balloon Pump, as it will improve coronary perfusion in diastole He is already on invasive ventilation, which is best way to improve oxygenation He needs PAMI, primary angioplasty in acute myocardial infarction as it will improve coronary perfusion and thus cardiac muscle contractility and prevent further death of myocardial muscle, however he has raised serum creatinine, it may prevent removal of contrast used in coronary angiography by kidney, aggravating the renal failure To prevent renal complication adequate urine output need to be ensured prior to PAMI, he may be given n acetyl cysteine to prevent contrast induced nephropathy Finally he is absolutely unfit for any surgical intervention for mitral/tricuspid regurgitation as he is highly unstable hemodynamically, besides having multiple risk factors

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ECG shoes ST segment elevation in lead II and III with reciprocal changes in lead I, along with Trop T positive It indicate hyperacute myocardial infarction Along with that he has pan systolic murmur indicating mitral/ tricuspid regurgitation Congestive cardiac failure Acute renal failure associated with hypotension, hypoxia He needs urgent ionotropic support to improve blood pressure to maintain perfusion of vital organs however ionotropic support will cause vasoconstriction of coronary artery and further aggravate ischaemia, therefore he needs, in addition, intra arterial balloon Pump, as it will improve coronary perfusion in diastole He is already on invasive ventilation, which is best way to improve oxygenation He needs PAMI, primary angioplasty in acute myocardial infarction as it will improve coronary perfusion and thus cardiac muscle contractility and prevent further death of myocardial muscle, however he has raised serum creatinine, it may prevent removal of contrast used in coronary angiography by kidney, aggravating the renal failure To prevent renal complication adequate urine output need to be ensured prior to PAMI, he may be given n acetyl cysteine to prevent contrast induced nephropathy Finally he is absolutely unfit for any surgical intervention for mitral/tricuspid regurgitation as he is highly unstable hemodynamically, besides having multiple risk factors

St elevation in II III avf with raciprocal ST depression in anterior leads along with v2-v6.. ACS acute IWMI with RVMI. poor prognosis..according to age and severity of MI

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Acute Inf + post wall mi with papillary muscle rupture leads to cardiogenic shock & acute pulmonary oedema Urgent PTCA O2 Dual antiplatelates Statins Diuretics Dopamine Noradrenalin BiPAP ventilation IABP for severely unstable patients. The cornerstone of treatment for papillary muscle rupture includes emergency surgical treatment. introperative mortality from mitral surgery is ~ 20%. Another treatment controversy is mitral valve repair v/s valve replacement—repair over replacement is currently preferred unless necrotic papillary muscle tissue is present.

Acute inf wall STEMI with RV infarct ..with papillary muscle rupture causing MR and pan systolic murmur and pul oedema Thrombolyse with tPA Stabilize with intubation mechanical ventilation pressor support But PAMI is more suitable as age is 80 and patient is in cardiogenic shock

Ecg shows st -t elevetion in2 3 avfand depression in1 avl and v2v3v4 with j formation of t in v3v4 and prominent q in 2 and 3 . This is a c/o ACS INF WALL MI with poor prognosis as vitals sre unstable

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Pt is of acute inferior MI.lead 1st avl chest leadv2 to v6 shows reciprocal changes may lateron to anterior MI extensive.Hypotension is feature of inferior Mi.Pansystolic murmur is due to anamia most likely leading to acute renal failure.pansystolic murmur may also be due to papilary muscle repture.Rx- treat The pt on the line Of management of acute MI.all symptoms will regress sequentially as the treatment progress.regular cheçk up and .follow up is must.

Inferior STEMI with involvement of posterior wall leading to Hypotension Pansysstolic murmur due to Acute MR (due to papillary n chordae tendinae involvement) Heart Failure Poor prognosis until PCI cn be performed

ACS - IWMI IN FAILURE (CREPITATIONS +) HAEMODYNAMICALLY UNSTABLE BP 70/? AGE 80YRS MANAGEMENT - ANTIPLATELETS,STATIN,NITRATES,IONOTROPES FOR HYPOTENSION DIURETICS AFTER BP STABILIZATION ELECTROLYTES CORRECTION IF PRESENT

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Acute inferior wall infarction with reciprocal changes in any leads as well as St segment depression in lateral leads suggestive of TVD adv urgent intervention & ICU management.ant,lead reciprocal changes.

Inferior wall MI. Needs regular monitoring and periodical evaluation of management.

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