case presentation and soap analysis on acute MI A 52 year old male patient admitted with Chest pain since 2 days & Aggravation at morning.

1. WELCOME

2. PATIENT PROFILE
NAME : XXXXX
AGE: 52 YEARS
SEX: MALE
DOA:1/11/2017
DOD:7/11/2017
IP NO: 214059

3. COMPLAINTS ON ADMISSION
 AGGRAVATION - MORNING
 CHEST PAIN FOR 2 DAYS

4.  MEDICAL HISTORY
 K/C/O SYSTEMIC HYPERTENSION
 C/O CHEST PAIN
 MEDICATION HISTORY: Not available
 SOCIAL HISTORY: Nil
 FAMILY HISTORY: Nil

5. PHYSICAL EXAMINATION
 GENERAL EXAMINATION
Conscious, oriented
 VITAL SIGNS
BP: 180/90 mmHg
PR: 100 beats/min
RHYTHM:Regular
 SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM:S1,S2 – Normal
CHEST – Clear
OTHER SYSTEMS: Normal

6. PROVISIONAL DIAGNOSIS
 CAD- ACUTE CORONARY SYNDROME
 ANTEROLATERAL MYOCARDIAL INFARCTION
 TWO VESSEL DISEASE
 S/P PRIMARY PTCA WITH STENTING TO LAD

7. BLOOD INVESTIGATION
HAEMATOLOGY
LEVEL NORMAL
WBC 17.3 4.6-10.3
NEUTROPHILL 82.5% 37-80
LYMPHOCYTE 12.8% 10-50
MONOCYTE 2.7% 0-12
EOSNOPHILL 1.7% 0-7
BASOPHILL 0.3% 0-2
RBC 5.97 4-6.13
HEMOGLOBIN 17.7g/dl 12.2-18.1
PLATELET 278 140-425
ESR 05mm/hr 1-25mm/hr

8. RENAL PROFILE
01/10 02/10 05/10 07/10 NORMAL
VALUES
FBS 95 70-110
mg/dL
RBS 178 150-200
mg/dL
BLOOD UREA 20 30 31 29 15-40
mg/dL
SERUM
CREATININE
0.8 0.9 1.0 1.0 0.6-1.6
mg/dL
SERUM
SODIUM
133 135 135-150
mEq/L
SERUM
POTASSIUM
3.5 3.5 3.5-4.4
mEq/L

9. LIPID PROFILE
01/10 NORMAL VALUES
CHOLESTROL 190 125-200 mg/dL
TRIGLYCERIDE 93 75-150 mg/dL
HDL 47 30-60 mg/dL
LDL 112 85-130 mg/dL

10. NON INVASIVE INVESTIGATION
 ECG - ANTEROLATERAL MI
 ECHO –
CAD, RWMA ( IVS,APEX,Apical Antero-lateral wall hypokinetic),
Moderate LV-Systolic dysfunction ,
CONCENTRIC LVH, Mild MR

11. FINAL DIAGNOSIS
 SYSTEMIC HYPERTENSION
 ACUTE CORONARY SYNDROME
 ANTERO LATERAL MYOCARDIAL INFARCTION
 TWO VESSEL DISEASE
 MODERATE LV SYSTOLIC DYSFUNCTION

12. DRUG CHART
DAY 1
Conscious,Oriented
BP :150/90mmHg
PR :100b/m
Primary PTCA stenting to LAD
CLOPIDOGREL loading dose 300mg
T.CLOPIDOGREL 75mg 1-0-1
T.ECOSPRIN 325mg 0-1-0
T.CARLOC 3.125mg 1/2-0-1/2
T.PANTOPRAZOLE 40mg 1-0-0
T.SORBITRATE 5mg 1-1-1
AGGRAMED INFUSION 6m/hr
T.NIKORAN 5 mg 1-0-1
INJ HEPARIN 8000 IU/ml
DAY 2
PR : 90/Min
BP : 120/80 mmHg
IP/OP : 1100/700 ml
T.CLOPIDOGREL 75mg 1-0-1
T.ECOSPRIN 325mg 0-1-0
T.CARDIVAS 3.125mg 1/2-0-1/2
T.PANTOPRAZOLE 40mg 1-0-0
NIKORAN 5 mg
INJ HEPARIN 4000 IU/ml
T. RAMIPRIL 2.5mg 1-0-0
T. IVABRADINE 5 mg 1-0-1

13. DAY 3
BP : 130/80
PR : 100/Min
IP/OP :1480/1650 ml
SAME AS DAY 2
DAY 4
BP : 110/70
PR : 80/Min
IP/OP : 1700/1500ml
ANGIOGRAM DONE
ABOVE DRUGS+
ECOSPIRIN 150mg 0-1-0
CLOPIDOGRL 1-0-0
DAY 5
BP : 110/70
PR : 72/Min
IP/OP : 1700/1500ml
PLANNED ELECTIVE PTCA
SAME AS DAY 4

14. DAY 6
BP : 110/70
PR : 64
IP/OP : 1600/1000
S/P ELECTIVE PTCA WITH STENTING
TO RCA
SAME AS DAY 4
DAY 7
BP : 100/60
PR : 60/Min
SAME AS DAY 4

15. DISCHARGE MEDICATION
DRUG
CLOPIDOGREL (CLOPILET 75) 1-0-0
ASPIRIN (ECOSPIRIN 150) 0-1-0
CARVEDILOL (CARDIVAS 3.15) ½ -0-½
PANTOPRAZOLE (PANTOCID 40) 1-0-0 (BEFORE FOOD)
NICORANDIL (NIKOS 5) 1-0-1
RAMIPRIL 2.5 1-0-0
IVABRADINE (IVAZINE 5) 1-0-1

16. SOAP ON MI

17. SUBJECTIVE
A 52 year old male patient admitted with Chest pain since 2 days
& Aggravation at morning.
OBJECTIVE
k/c/o Systemic hypertension
BP : 150/90
PR :100/Min
Rhythm : normal
S1 , S2 : normal

18. ECG reports shows that the patient has anterolateral MI
ECHOCARDIOGRAPHY : CAD , Regional Wall Motion Abnormalities ( Antero-lateral wall
hypokinetic) , LV systolic dysfunction (EF=35%) concentric LVH, mild MR
ASSESSMENT
Based on the subjective evidences the patient is diagnosed to have
myocardial infarction

19. DRUG CONTENT DOSE FRQNCY DAY
1
DAY
2
DAY
3
DAY
4
DAY
5
DAY
6
DAY
7
DOD
T.CLOPILET CLOPIDOGREL 300mg loading 
T.CLOPILET CLOPIDOGREL 75mg 1-0-1   
T.CLOPILET CLOPIDOGREL 75mg 1-0-0     
T.ECOSPIRIN ASPIRIN 325mg 0-1-0   
T.ECOSPIRIN ASPIRIN 150mg 0-1-0     
T.CARDIVAS CARVIDILOL 3.125mg ½ - 0-½        
T.PANTOP PANTOPRAZOLE 40mg 1-0-0        
T.SORBITRATE 5mg 1-1-1 
AGGRAMMED
INFUSION
TIROFIBAN 6ml/hr 
T.NIKORAN NIKORANDIL 5mg 1-0-1        
Inj.HEPARIN HEPARIN 8000IU/ml       
T. RAMIPRIL RAMIPRIL 2.5mg 1-0-0       
T.IVAZINE IVIBRADINE 5mg 1-0-1       

20. PLANNING
DRUG
T.CLOPIDOGREL Reduce atherosclerotic event
T.ASPIRIN Anti-platelet
T.CARVIDILOL Antihypertensive,anti-anginal
T.PANTOPRAZOLE Reduce gastric irritation
T.ISOSORBIDE
DINITRATE
Reduce chest pain
INJ.TIROFIBAN Prevent formation of blood clots
T.NIKORANDIL vasodilator
Inj.HEPARIN anticoagulant
T.RAMIPRIL antihypertensive
T.IVIBRADINE antianginal

21. DISCUSSION
MYOCARDIAL INFARCTION
A diseased condition caused by reduced blood flow in a coronary artery due to
atherosclerosis and occlusion of an artery by thrombus. It is the rapid development of
myocardial necrosis by a critical imbalance between oxygen supply and demand to the
myocardium.
CAUSES
REGARDING DISEASE
Rupture of an atherosclerotic lesion within coronary wall
Coronary artery vasospasm
Ventricular hypertrophy
Hypoxia
Coronary artery emboli
Increased afterload which increases myocardial demand

22. RISK FACTORS
Age
Male gender
Smoking
Hypercholesterolemia and triglyceridemia
Diabetes Mellitus
Poorly controlled hypertension
Family History
Sedentary lifestyle
HYPERTENSION
condition in which the blood pressure in the arteries is persistently elevated. It is a major risk factor
for coronary artery disease, stroke, heart failure, peripheral vascular disease.

23.  For the reduction of atherosclerotic events like MI and stroke.
 MOA: Inhibitor of platelet aggregation , selectively inhibits binding of ADP to
its receptor.
 Taken with or without food.
 ADR: GI bleeding, rashes , diarrhoea, abdominal pain.
 CI :Hypersensitivity, Use during hemorrhagic disorders causes GI bleeding.
T.CLOPIDOGREL ( CLOPILET75 mg )
REGADING MEDICATION

24.  Antiplatelet agent.
 MOA : It inhibits cyclooxygenase, which is responsible for the synthesis of
prostaglandin and thromboxane. It also inhibits platelet aggregation.
 ADR:GI bleeding ,thrombocytopenia,bleeding disorders, rashes .
 CI: hypersensitivity,G6PD deficiency , hepatic impairment , GI lesions etc.
T.ASPIRIN (ECOSPIRIN150 mg)

25. CARVEDILOL (CARDIVAS 3.125MG)
CATEGORY: Antihypertensive, anti-anginal
MOA : Binds to beta adrenergic receptors , inhibition of these receptors leads to
deceased heart rate & contractility
CI: Bronchial asthma, cardiogenic shock, bradycardia
ADR: Hypotension, edema, rash, pruritis, hyperkalemia

26. NICORANDIL (NIKORAN 5MG)
CATEGORY: Vasodilator
MOA: stimulates formation of cyclic GMP, which activates protein kinase G &
decreases Ca sensitivity of smooth muscle
CI : hypersensitivity
ADR: headache, skin ulcer, palpitations, vomiting

27. RAMIPRIL (2.5mg)
CATEGORY: ACE inhibitor, antihypertensive
DOSE: 2.5mg orally od
MOA: inhibit ACE, lowering pdtn of angiotensin II, causes relaxation of arteriole
smooth muscle & decrease in peripheral resistance
CI: Angioedema, renal impairment
ADR: hypotension, dry cough, hyperkalemia

28. IVABRADINE (IVAZINE 5mg)
CATEGORY: Antianginal
DOSE: 5mg orally bd
MOA: reduces cardiac pacemaker activity, slowing heart rate & allowing more
blood flow to myocardium
CI: hypotension, hepatic impairment, sick sinus syndrome
ADR: bradycardia, rash, visual impairment

29. • MOA : Degrade tissue macrophages and inactivate clotting factor x.
• ADR ; Bleeding disorder, thrombocytopenia,rarely hypersensitivity,
hyperkalaemia.
• CI : Severe hypertension,bleeding disorders, cirrhosis, renal failure
• DI : Cephalosporin : increased risk of bleeding.
Nitroglycerin : efficacy of heparin decreased.
Penicillin : addictive effects on heparin,increased risk of bleeding.
INJ. HEPARIN4000 IU

30. Tab. PANTOP (Pantoprazole 40mg)
-Indication:GERD,Peptic ulcer
- Proton pump inhibitor, Reduces gastric acid secretion
-Special precaution:Long term use may lead to bacterial overgrowth in GI
tract and hepatic impairment
-ADR:Diziness,pruritis,skin rashes,GI tract infection

31. T.isosorbide dinitrate (SORBITRATE 5mg)
 CATEGORY: Nitrates
 MOA: It works by relaxing & widening blood vessels so blood can
flow more easily to the heart.
 USES :Heart failure, esophageal spasms, prevent chest pain in
patients with certain heart conditions.
 SE: Headaches, dizziness, nausea, flushing.

32. Patient Counselling Points
REGARDING DISEASE
Maintain a low cholesterol diet.
Substitution of non-hydrogenated saturated fat & trans fat in the
diet.
Conception of omega3 fatty acids (primary source is fish).

33. BLOOD PRESSURE CHECKED : high blood pressure (hypertension) is a
major risk factor for heart attack .
normal BP is 120/80mmHg.
CHOLESTEROL CHECKED : As high risk for MI, LDL “Bad” Cholesterol
should be lower than 100mg/dl.
WEIGHT MANAGEMENT: BMI between 18.5-24.9kg/m2.

34. REGARDING DRUGS
 Tab.Ecospirin
- High dose long term therapy causes GI bleeding
- Take drug with food or after meal to avoid GI upset
- Keep out of reach of children
•INJ HEPARIN
- Inform doctor or dentist or other health care providers of heparin
therapy.
- take advise consulting prescriber before taking any other drugs
including OTC drugs

35. TAB.CLOPIDOGREL
- It may take longer to stop bleeding;retrain from activities in which trauma and bleeding may
occur
- Care should be taken while driving
- Inform doctor or dentist of clopidogrel use before scheduling surgery or taking new drug
PANTOPRAZOLE (PANTOCID 40 mg)
•Do not miss the doss
•Take the drug 30 min before food
•May cause diarrhea, dizziness, pruiritis , skin rashes
•Tablet should not be chewed or crushed

36. TAB.CARVEDILOL 3.125 mg
 Take tablet either with or without food, but try to take doses at the same time of
day .
 Do not take two doses together to make up for a forgotten dose.
 Eat healthy diet , do not smoke & take regular exercise.
TAB. NICORANDIL 5MG
Take one tablet twice daily, in the morning & evening.
 Take tablets either before or after meals.
 Swallow the tablet with a drink of water.

37. TAB. RAMIPRIL 2.5 MG
 The 1st dose may make you feel dizzy, so it is best taken at bed time.
 Commonly taken as once daily dose.
 Take tablet either with or without food.
 Patient should avoid potassium containing supplements while taking this drug.
 Tell patient to report signs/symptoms of angioedema (deep swelling around
eyes/lips and sometimes hands and feet)

38.  Aspirin and Clopidogrel are interacted with Heparin.Moniter closely
 C-reactive proteins and troponin values are not checked.
 Heparin and pantoprazole may increase risk for osteoporosis hence
multivitamin tablets should be given.
 Normally Aspirin 150 is administered for patients with CAD or anginal pain but
here Aspirin 325 is given.
 Clopidogrel is supposed to be given once a day but in this case it is given twice.
PHARMACISTS
INTERVENTION