-Myocardial Infar
Transcript of -Myocardial Infar
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Presentation onPresentation on
myocardial infarctionmyocardial infarction
ByBy-- Dr.Vinay VatsayanDr.Vinay Vatsayan
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Presenting Symptoms of Acute
MI Pain-
*typical-crushing substernal chest pain
*atypical - jaw, neck, shoulder, back pain,
indigestion*painless - silent
Dyspnea-
systolic and/or diastolic dysfunction
Dizziness-hypotension, arrhythmia
Nausea, vomiting
Elderly patients: Failure to thrive
Anxiety, restlessness, sense of impending doom
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Presenting Signs in Acute MI
Appearance: Pallor, diaphoretic, anxious
Vital Signs: Normal or abnormal BP and P
Hypertension and tachycardia: SNS
Hypotension and tachycardia:
Cardiogenic shock
Myocardial rupture
Tachyarrhythmia
Hypotension and bradycardia
vagal stimulation
Bradyarhythmia
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Presenting Signs in Acute MI
(Cont.)
Lungs: Rales - CHF
Heart: Displaced LV impulse
S3
S4
Murmur of mitral regurgitation
Murmur of ventricular septal
rupture
Pericardial rub
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Evolution of ECG changes in acute MI
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Cardiac enzymes
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Natural History of Acute
Myocardial Infarction Death-
Arrhythmia: VT/VF
Asystole Myocardial rupture
Cardiogenic shock
ChronicHeart Disease -
LV dysfunction - remodeling
Papillary muscle dysfunction: MR
RV dysfunction
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Natural History of Acute
Myocardial Infarction, (Cont.)
Stabilizationpcompensated LV
dysfunction Post-infarction angina/ischemia
(spontaneous or induced)
Recurrent MI Post-infarction ventricular
tachycardia
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Treatment of Acute Myocardial
Infarction: Acute Phase Prevent/resuscitate from sudden
death: monitor, admit to CCU
Re-establish coronary flow
Thrombolytic therapy
Primary infarct angioplasty/stent
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Major Contraindications To the Use of
Thrombolytic Therapy
Any previous history of hemorrhagic stroke
History of stroke, dementia, or central nervous system
damage within 1 year
Head trauma or brain surgery within 6 months Known intracranial neoplasm
Suspected aortic dissection
Internal bleeding within 6 weeks
Active bleeding or known bleeding disorder
Major surgery, trauma, or bleeding within 6 weeks
Traumatic cardiopulmonary resuscitation within 3
weeks
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Treatment of acute MI:
acute phase (cont.) Decrease myocardial oxygen demand
Pain relief/anxiolytics (Morphine sulfate)
SlowH
R, control BP (beta blockers) Increase myocardial oxygen supply
Oxygen
Prevent platelet aggregation/coronarythrombus (aspirin, IIbIIIa inhibitors,
clopidigrel/heparin) Prevent spasm (nitrates)
Augment collateral flow (nitrates)
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Treatment of Acute Myocardial
Infarction: Acute Phase (C
ont.)
Stabilize plaques, restore endothelialfunction
?HMGCoA reductase inhibitors (statins)
Prevent ventricular remodeling
ACE inhibitors
Prevent mural thrombus/embolization
Heparin
Coumadin for patients at high risk forthrombus (anterior wall akinesis).
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Treatment of Acute Myocardial
Infarction - Intermediate Phase Monitor/treat arrhythmias
Monitor/treat heart failure: systolic,
diastolic, MR
Monitor/treat recurrent ischemia/infarction
Watch for pericarditis, Dresslers Syndrome
Monitor for myocardial rupture (free wall,VSD, MR)
Monitor for stroke
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Determinants or Prognosis
after Acute MI
LV function (ejection fraction)
Inducible ischemia/coronary anatomy Arrhythmia potential
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Tests for LV function
Echocardiogram
Radionuclide ventriculogram(MUGA)
Contrast left ventriculogram (cath)
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Echocardiogram in Acute
Myocardial Infarction
Wall motion abnormalities
Ejection fraction
Thrombus
Right ventricular MI
Papillary muscle dysfunction- mitral
regurgitation
Free wall rupture/ventricular septal
defect/papillary muscle rupture
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Test for Inducible ischemia:
Stress Test 1. Positive: Ischemic ST segment
depression - u1mm horizontal or
downsloping ST depression
2. Negative: Patient reaches 85%
maximum predicted heart rate (MPHR)
without #1
3. Nondiagnostic: No ischemia but patient
fails to reach 85% MPHR
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Test to Define Coronary
Anatomy: Coronary
Angiogram
Controversy: Should all patients
undergo coronary angiogram after anMI?
Definite indications for coronary
angiogram after MI:
Recurrent chest pain
Positive stress test
High risk features: CHF, low EF, prior MI
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Risks ofCoronary
Angiography: (all are rare)
Stroke
Myocardial infarction Arrhythmia
Renal failure
Allergic reaction to contrast agent
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Tests to Determine Arrhythmia
Risk:
Monitoring throughout
hospitalization Stress test
Electrophysiologic testing
Controversy: Who should undergo EPstudy after MI?
Sustained VT
Nonsustained VT with depressed ejection
fraction
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Treatment of Acute Myocardial Infarction
Late Phase (Post-Hospital)
Risk factor reduction:
Smoking
Hypertension
Diabetes
Dyslipidemia
Obesity/sedentary life style
Hyperhomocysteinemia
Stress/depression
Monitor for recurrent ischemia
Monitor for LV remodeling/CHF
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ABCs of Treatment and
Secondary Prevention of AMI Aspirin-prophylactic Rx for recurrent ischemic events;
give for at least 3 mo. after AMI, probably indefinitely
Beta blockers-prophylactic, for reduction of cardiac
mortality; Rx for 2 yr-indefinitely
Converting enzyme inhibitors-all pts with LV
dysfunction to reduce risk of progressive heart failure
and death.
Diet and lipid lowering Rx-statins have been shown
to reduce risk of subsequent MI, need for
revascularization and mortality (4S, Care)
Exercise and rehabilitation-essential in restoration of
confidence and improvement in quality of life
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Creatine Phosphokinase (CK)
Rises within 4-8 hours, rapidly cleared by 24-24 hours
Other Sources:
Skeletal
Hypothyroidism Renal failure
Stroke
Isoenzymes
MM skeletal muscle
BB brain
MB cardiac
CKMBu 4% suggests acute myocardial infarction+++
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Cardiac Specific Troponins
(cTnT, cTnI)
Rise within 4-8 hours, remain elevated7-14 days (T>I)
30% of patients with UAP show o
levels cTnT or I, indicating increased
risk of adverse outcome
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Relative Contraindications To the Use of
Thrombolytic Therapy
Oral anticoagulant therapy
Acute pancreatitis
Pregnancy or within 1 week postpartum
Active peptic ulceration
Transient ischemic attack within 6 months
Dementia
Infective endocarditis
Active cavitating pulmonary tuberculosis
Advanced liver disease
Intracardiac thrombi
Uncontrolled hypertension (systolic blood Pressure >180 mm Hg, diastolic blood
pressure > 110 mm Hg
Puncture of noncompressible blood vessel within 2 weeks
Previous streptokinase therapy