Friday, November 10, 2006

Ex PM admitted with chest pain

The news was all over town yesterday. "Have you heard that the Ex PM has been admitted to IJN with chest pain?".

As such, this is a great time to talk about chest pain. Let's talk about the current case in the press based on the publicly available information. First, the patient's history. We know that in 1998 (I remember because that's when I shifted my practice to SJMC), he took a heart attack. He drove himself to GHKL and was admitted. He had an angiogram done in GHKL by a visiting American Cardiologist (Dr S.Stertzer- St Francisco HC, Seton City) and was found to have a left mainstem stenosis and 3V-CAD. He underwent CABG (done by Tan Sri Dr Yahaya Awang) and since then has been presumably well.

There were occasional rumours that he had further angioplasty. He is also a known diabetic (T2DM). He is 80+ years old. Any chest pains at this point in time considering the stress++ that he is under (his pesonality, politics and all that travelling ), must be presumed to be cardiac, in which case, he would be hospitalised in the CCU (coronary care unit) and be subjected to an ECG (or more then one), cardiac enzyme estimation and troponin T estimation. He must have had a whole biochemistry profile, in view of his age and diabetes.

The mass media is carrying various diagnosis varying from unstable angina, or what we now call acute coronary syndrome, and a mild heart attack, which could be STEMI (ST elevation myocardial infarction) or NSTEMI (non-ST elevation myocardial infarction).

Now the science. Acute coronary syndrome describes chest pains of cardiac origin, with ECG changes (without Q-waves) and no elevation of cardiac enzymes and a negative troponin T. A mild heart attack would mean chest pains of cardiac origin, with ECG changes of ST elevation, only in certain leads (limited), and elevations in cardiac enzymes.

Sometimes the ECG does not show ST elevation but instead shows ST depression. The former variety is called STEMI and the latter NSTEMI. I would expect by now that he would be on LMWH (low molecular weight heparin) and oral clopidogrel, if the diagnosis is acute coronary syndrome. Once he is free of chest pains and hemodynamically stable, I am sure that his cardiologist will schedule a coronary angiogram. If indeed he took a mild heart attack, his cardiologist may give him IV thrombolytic therapy, then get him stable for a coronary angiogram. Of course, the dangers from LMWH and IV thrombolytic therapy includes bleeding.

On the basis of his coronary angiogram findings, depending on the coronary pathoanatomy, he may either undergo an angioplasty (much prefered) or a repeat CABG. I wonder which foreign interventionist will be called to help with the angiogram/angioplasty. An octogenarian is always a risky subject for angioplasty, adding to it a post CABG patient with diabetes mellitus. These are all risk factors for angioplasty, and CABG too.

Well we wish him a speedy recovery, November will be a difficult month for Tun Dr Mahatir Mohammed.

1 comment:

cytusm said...

Was it 1989 or 1998?