w
Myocardial Infarction: 
Amphetamine abuse: 
Case Study:

- Definition. -Common names. -Case scenario

- classification. -Reasons for abuse -Physical exam
- Signs & Symptoms. -Mechanism of action -History
- Causes. -Side effects -Lab results
- Risk factors. - Withdrawal Symptoms -Final Diagnosis
- Diagnosis. - Management of -Medications
- Management. toxicity -Assessment
 Definition.

Mana e ent. classification.

i ns
Dia nosis.
y to s.

Risk factors. Causes.

Ú In a myocardial infarction the heart

muscles suffer a prolonged and severe

restriction of oxygenated blood.

Ú This is most commonly due to occlusion of

a coronary artery following the rupture of

a vulnerable atherosclerotic plaque.

Ú The resulting ischemia if left untreated for

a sufficient period of time, can cause

damage of the myocardium

 w- °


I v lv s t tir t ick ss f t
l ft v tric lar all fr
car i t icar i .

2- 


:
I v lv s ltif cal ar as f cr sis
c fi t t i rw
rw 2 ft
l ft v tric lar all.
ST elevation Normal Non ST
MI ECG Elevation MI
- Persistent, severe chest pain. The pain generally begins in
the chest and radiates to the left arm, back neck and jaw.

- Pain persists for longer than
 min and is unrelieved by

NTG.

- Some patients; particularly diabetic and hypertensiveǯs

may experience abdominal pain resembling indigestion.

- Other complaints: a sense of impending doom, nausea,

vomiting, sweating, difficulty breathing.
 Coronary artery vasospasm

Ventricular hypertrophy

Hypoxia

Coronary artery emboli

Cocaine, amphetamines, and ephedrine.

 Family
Tobacco
Diabetes Hyperlipidemia history of
smoking
IHD

Hypertension Obesity Stress Alcohol

High
Males over Females
homocysteine
levels. 45yr over 55yr
Troponin.
Creatine
kinase.
Myoglobin.
Ú Myocardial muscle creatine kinase (CK-MB), which is found mainly in the heart .

Ú A level within the reference range does not exclude myocardial necrosis.

Ú CK-MB may not be affected by very small infarcts.

Ú Myoglobin, a low-molecular-weight heme protein found in
cardiac and skeletal muscle.
Ú Myoglobin levels are highly sensitive but not specific
 Chest
Radiography

Echo
cardiograph
 Electrocardiography

Complete blood count

Chemistry profile

C-reactive protein (CRP)

Erythrocyte sedimentation rate (ESR

Serum lactate dehydrogenase (LDH)

ÚThe management of STEMI and NSTEMI differ in:

STEMI:
Ȉ Is due to sudden thrombotic occlusion.
Ȉ The mainstay of treatment is thrombolytic therapy

NSTEMI
Ȉ Is due to an unstable plaque with aggregation of
platelets.
Ȉ The mainstay of treatment is anti platelet drugs
and anticoagulants.
w- Thrombolytic agents
2- Antithrombotic agents

- Platelet aggregation inhibitors
4- Nitroglycerin
5- eta blockers
6- ACE inhibitors
7- Analgesics
Alteplase &
Tenecteplase.
Streptokinase.
 Alteplase Tenecteplase

Ȉ Very short half life, so Ȉ Dose: Give IV bolus over

adjunctive Heparin 5 s using body weight
therapy is needed. dosing.
Ȉ Dose: Dose: w5 mg IV Ȉ not to exceed 5 mg.
bolus then .75 mg kg Ȉ <6 kg:
 mg (6 mL)
IV over
 min. 6-7 kg:
5 mg (7 mL)
Ȉ Contraindications: 7-8 kg: 4 mg (8 mL)
stroke within last 2 8-9 kg: 45 mg (9 mL)
months & severe >9 kg: 5 mg (w mL)
uncontrolled
hypertension.
Ú Streptokinase forms a complex with plasminogen which
then converts plasminogen to plasmin. Plasmin breaks
down clots as well as fibrinogen and other plasma
proteins.

Ú Dose: w.5 million U in 5 mL D5W IV over 6 min.

Ú Caution in severe hypertension.

 Ȉ Inhibits cyclooxygenase, which produces
R   thromboxane A2, a potent platelet activator.
Ȉ Dose: w6-
24 mg PO .

Ȉ Augments activity of antithrombin III and prevents

conversion of fibrinogen to fibrin.

  

Ȉ Dose: 6 U kg (max 4 U) IV bolus; followed by a w2
U kg h (max w U h) maintenance infusion.

Ȉ Inactivates activated factor X & factor II.

Ȉ Advantages include intermittent dosing and decreased
   requirement for monitoring.
Ȉ Dose: NSTEMI = w mg kg SC bid
Ȉ STEMI=
 mg IV single bolus plus w mg kg SC
O
    R 

Chimeric human-
Inhibits ADP binding murine monoclonal
to platelet receptor Antagonist of the antibody Binds to
GP2b
a complex, platelet glycoprotein receptor with high

thereby inhibiting (GP) IIb IIIa receptor affinity and reduces

platelet aggregation. platelet aggregation by

8

Dose: .25 mcg kg IV

Dose: .4 µg kg min
Dose: 75 mg PO IV for
 min
bolus, followed by w
mcg min IV for w2 h
Ú Causes relaxation of vascular smooth muscle by stimulating
intracellular c-GMP production.
Ú Dose: 4 mcg SL
if symptoms persist, infuse IV at a rate of 5-w mcg min

   

Selective betaw-adrenergic Selective betaw-adrenergic

receptor blocker receptor blocker

Loading dose: 5 µg kg min IV

over w min
Dose: 5 mg IV q. 5 min TID
Maintenance dose: .w
mg kg min IV
Ú These agents prevent conversion of angiotensin I to angiotensin
II, a potent vasoconstrictor, causing lowered aldosterone
secretion.

Ú Has short half-life, which makes it important drug for initiation

of ACE inhibitor therapy.

Ú Dosing: 6.25 mg PO TID ; may titrate to total 45 mg d

Ú May provide some preload reduction as well as reducing pain
and ensuring patient comfort.

Ú DOC for analgesia because of reliable and predictable effects,

safety profile, and ease of reversibility with naloxone.

Ú Dose: w-
mg IV; repeat and titrate to pain relief.

Ú Is suitable for patients with the clinical presentation of
STEMI within w2 h after symptom onset and with
persistent ST-segment elevation.

Ú Indicated for patients in shock and those with

contraindications to thrombolytic therapy irrespective
of time delay.
ÚFacilitated PCI is defined as a pharmacological
reperfusion treatment delivered prior to a planned
PCI.
ÚFull-dose thrombolytic therapy
ÚOr half-dose thrombolytic therapy with a
glycoprotein (GP)IIb IIIa inhibitor.
Ú Rescue PCI is defined as PCI performed on a coronary
artery which remains occluded despite thrombolytic
therapy.

Ú Clopidogrel should be given as soon as possible to all

patients with STEMI undergoing PCI.

Ú Loading dose =
 - 6 mg

Ú Followed by a daily dose of 75 mg.

 Common
names.
Management Reasons for
of an abuse
overdose

Withdrawl Mechanism
Effects of action

Side effects
 Ë








 
 
A study drug A party drug

A weight-loss
drug
Ú Increases the levels of
dopamine, serotonin, and
norepinephrine in the central
nervous system.

Ú The major neural systems

affected by amphetamine are
largely implicated in the brainǯs
reward circuitry.
Physical:
Ú anorexia Ú drymouth Ú hypertension
Ú dilated pupils Ú tachycardia Ú acne
Ú hyperactivity Ú tachypnea Ú heart attack

Psychological:
Ú euphoria, Ú sociability
Ú anxiety Ú aggression
Ú concentration Ú grandiosity
Ú self-confidence Ú paranoia
 fatigue

mental
depression

excessive sleep

vivid or lucid dreams

suicidal ideation.
When oral toxicity is recent activated charcoal may be given.

Benzodiazepines are the preferred initial treatment for CNS excitation,

seizures, tachycardia, and hypertension.

Propofol with mechanical ventilation, may be required for severe

agitation.

Hypertension that does not respond to benzodiazepines is treated

with nitrates.

Ⱦ-Blockers may be used for severe ventricular arrhythmias or

tachycardia.
 Case
scenario
Physical
Assessment
exam

Medications History

Final
Lab results
Diagnosis
Ú A
2 year old Saudi man was admitted on Dec w4th 2w through
the ER.

Ú O  


chest pain for more than 2 hours numbing in

nature & radiating to both shoulders & arms. Pain was aggravated
by lying down & decreased by sitting.

Ú He was discharged 4 days later on Dec w8th 2w.

 þ

 Ȉ Conscious but in pain

Blood pressure Ȉ w9 w2 mmHg

Heart Rate Ȉ w5 Beats min

Chest Ȉ Dyspnea

ECG Ȉ ST elevation
 Drug addict Heavy
Known case ( 5 tablets of cigarette
HTN > 2yrs amphetami smoker 2
ne day ) packs day
 °
  

  


pCO2 6.97  (4.7 Ȃ 6.w) Kpa

pO2
.4
 (2w Ȃ 26) mmol l

Na w
  (w
5-w45)mmol l
Random Glucose 7.
 (
.9 Ȃ 6.7) mmol l
LDH 229  (w Ȃ w9) U l

Trop .w9  ( Ȃ .w) µg l

CK
29  (2w-2
2) IU l
 › 


 




›








 

ASA Anti-platelet w62 mg OP OD Bleeding

Clopidogrel Anti-platelet 75 mg O.P OD Bleeding

Simvastatin stabilize the thrombus 4 mg O.P OD Abdominal pain

Captopril Antihypertensive 6.25mg OP TID Hyperkalemia

Enoxaparin Anti coagulant 8 IU S.C Bleeding

Ranitidine Stress ulcer 5 mg I.V TID dizziness

Tenecteplase Thrombolytic 8 mg OD I.V Bleeding

Diazepam Amphetamine OD 5 mg OD Sedation.

Ú Close monitoring for development of hypotension is
recommended due to Coadministration of diazepam
and captopril.

Ú Concomitant use of Captopril and Enoxaparine may

increase the risk of hyperkalemia. Serum potassium
and renal function should be checked regularly.
Ú http: www.Drugs.com

Ú http: www.merckmanuals.com professional secw5 chw98 chw98k.html

#secw5-chw98-chw98c-27
b

Ú http: emedicine.medscape.com article 8w25w8-overview

Ú http: www.medicinenet.com script main hp.asp