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Attribution: Kim Eagle, M.D., 2012
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Kim A. Eagle, M.D.
University of Michigan Cardiovascular Center
Acute Coronary SyndromesAcute Coronary Syndromes(ACS)(ACS)
Cardiovascular SequenceCardiovascular Sequence
Fall 2012Fall 2012
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Kim A. Eagle, MDKim A. Eagle, MDDirectorDirector
University of MichiganUniversity of MichiganCardiovascular CenterCardiovascular Center
Grants: NIH, Hewlett Foundation, Mardigian Grants: NIH, Hewlett Foundation, Mardigian
Foundation, Varbedian Fund, GOREFoundation, Varbedian Fund, GORE
Consultant: NIH NHLBIConsultant: NIH NHLBI
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Acute Coronary SyndromesAcute Coronary SyndromesKey Words: ST elevation MI, non-STE, ACS, cardiac
biomarkers, treatment of ACS, mechanical complications of MI
Objectives:
1.To learn how the admission ECG dictates early therapy for ACS.
2.To learn how to use cardiac biomarkers to diagnose ACS.
3.To become familiar with strategies for treatment in ACS.
4.To become familiar with mechanical complications of ACS.
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Lecture OutlineLecture Outline
• Pathogenesis of ACS
• Clinical features of ACS
• Treatment of ACS
• Complications
• Post ACS risk stratification
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Pathogenesis of ACSPathogenesis of ACS
• Normal hemostasis
• Endogenous antithrombotic
mechanisms
• Pathogenesis of coronary thrombosis
• Nonatherosclerotic causes of ACS
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Pathogenesis: ACSPathogenesis: ACS
• > 90% - plaque disruption with platelet
aggregation intracoronary thrombus
• Concepts of clot formation
• Continuum of ACS from unstable angina
to STE MI
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Acute Coronary SyndromesAcute Coronary Syndromes
Unstable anginaUnstable angina ST-Elevation MIST-Elevation MI(Q-wave MI)(Q-wave MI)
Non-ST Elevation MINon-ST Elevation MI(Non-Q-wave MI)(Non-Q-wave MI)
Stable CADStable CAD
The continuum of acute coronary syndromes ranges from unstable The continuum of acute coronary syndromes ranges from unstable
angina, through non-ST-elevation myocardial infarction (also referred angina, through non-ST-elevation myocardial infarction (also referred
to as to as ““non-Q-wavenon-Q-wave”” myocardial infarction [MI]), to ST-elevation MI myocardial infarction [MI]), to ST-elevation MI
(also referred to as (also referred to as ““Q-waveQ-wave”” MI). MI).
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Normal HemostasisNormal Hemostasis
• 1st defense Platelets
– “Primary hemostasis” Platelet plug
• 2nd defense Subendothelial
– Tissue factor activates plasma
– Coagulates proteins
“Secondary hemostasis” Fibrin clot
Vessel wall injury
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Endogenous Antithrombotic Endogenous Antithrombotic MechanismsMechanisms
Inactivation of clotting factors• Antithrombin III
• Protein C / Protein S / thrombomodulin
• Tissue factor pathway inhibitor
Lysis of fibrin clots• Tissue plasminogen activator
Endogenous platelet inhibition & vasodilation• Prostacyclin
• Nitrous oxide
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Endogenous Protective Endogenous Protective MechanismsMechanisms
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 170
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Triggers to Plaque RuptureTriggers to Plaque Rupture
Inflammatorycytokines
Plaque RupturePlaque Rupture
Physical Stress
VulnerablePlaque
EmotionalStress
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Mechanisms ofMechanisms ofCoronary ThrombosisCoronary Thrombosis
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 171
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Consequences ofConsequences ofCoronary ThrombosisCoronary Thrombosis
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 173
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Causes of Acute Coronary Causes of Acute Coronary SyndromesSyndromes
• Atherosclerosis with superimposed thrombus
• Vasculitic syndromes
• Coronary emboli (e.g., from endocarditis, artificial valves)
• Congenital anomalies of the coronary arteries
• Coronary trauma or aneurysm
• Severe coronary artery spasm (primary or cocaine-induced)
• Increased blood viscosity (e.g., polycythemia vera, thrombocytosis)
• Significantly increased myocardial oxygen demand (e.g., aortic stenosis)
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Extent of Myocardial InjuryExtent of Myocardial Injury
• LV mass perfused by vessel
• Magnitude/Duration of flow
• Oxygen demand of affected tissue
• Adequacy of collaterals
• Tissue response to ischemia
Determined by:Determined by:
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Acute Coronary SyndromesAcute Coronary Syndromes
Unstable anginaUnstable angina ST-Elevation MIST-Elevation MI(Q-wave MI)(Q-wave MI)
Non-ST Elevation MINon-ST Elevation MI(Non-Q-wave MI)(Non-Q-wave MI)
Stable CADStable CAD
The continuum of acute coronary syndromes ranges from unstable The continuum of acute coronary syndromes ranges from unstable
angina, through non-ST-elevation myocardial infarction (also referred angina, through non-ST-elevation myocardial infarction (also referred
to as to as ““non-Q-wavenon-Q-wave”” myocardial infarction [MI]), to ST-elevation MI myocardial infarction [MI]), to ST-elevation MI
(also referred to as (also referred to as ““Q-waveQ-wave”” MI). MI).
Clinical Features: ACSClinical Features: ACS
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Unstable AnginaUnstable Angina
• Prior stable angina in:
– Frequency
– Duration
– Intensity
• Angina at rest… previously only on provocation
• New onset angina
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Acute Myocardial InfarctionAcute Myocardial Infarction
• History and exam
• EKG changes
• Serum markers
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SymptomsSymptoms
Pain
Sympathetic response
Parasympathetic response
Inflammatory response
Other
– PressurePressure– Burning (hot)Burning (hot)– Chest/arms/jaw/backChest/arms/jaw/back
– SweatsSweats– TachycardiaTachycardia– Cool, clammy skinCool, clammy skin
– NauseaNausea– VomitingVomiting– WeakWeak
– Mild feverMild fever
– DyspneaDyspnea– AsymptomaticAsymptomatic
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Physical FindingsPhysical FindingsPhysical FindingsPhysical Findings
• Inspection
BP - often increase anterior MI
- often decrease inferior MI
HR - often increase anterior MI
- often decrease inferior MI
RA po - increase in RV MI
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Physical FindingsPhysical FindingsPhysical FindingsPhysical Findings
• Palpation
LV Bulge - dyskinetic anterior wall
• Auscultation
Gallop - S4-LV stiff
Sounds - S3-LV fatigue
Murmurs - Mitral regurgitation
- VSD
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Differential DiagnosisDifferential DiagnosisDifferential DiagnosisDifferential Diagnosis
• CardiacPericarditis - Sharp, pleuritic pain
- PT prefers to sit
- Friction rub
- EKG diffuse STE
Aortic Dissection - Instantaneous onset of severe pain
- Pulse deficits or AI
- Wide mediastinum (CXR)
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Differential DiagnosisDifferential DiagnosisDifferential DiagnosisDifferential Diagnosis
• Pulmonary
Pulmonary Embolus - Pleuritic pain
- Dyspnea
- Reason for clotting
Pneumonia - Cough, sputum, fever - Consolidaton changes
• Gastrointestinal
Esophageal Spasm - Retrosternal burning (acid)
- After meals or at night
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Diagnosis of ACSDiagnosis of ACS
Typical symptoms Crescendo, rest, or new
onset severe angina
Serum biomarkers No Yes Yes
ECG initial findings ST depression and/or ST depression and/ ST elevation (and Q
T wave inversion or T wave inversion waves later)
Unstable Angina Myocardial Infarction
Prolonged “crushing” chest pain, more
severe and wider radiation than usual angina
NSTEMINSTEMI STEMISTEMI
NSTEMINSTEMI, non-ST-elevation myocardial infarction (MI); , non-ST-elevation myocardial infarction (MI); STEMISTEMI, ST-elevation MI, ST-elevation MI
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Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 182
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Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 182
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Serum Markers ofSerum Markers ofMyocardial InfarctionMyocardial Infarction
Serum Markers ofSerum Markers ofMyocardial InfarctionMyocardial Infarction
• Myocardial necrosis causes sarcolemma
disruption
• Intracellular macromolecules are released
• Can be measured by serial blood testing
• Pattern and level of rise correlates with
timing and size of MI
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Cardiac-Specific TroponinsCardiac-Specific Troponins
• Regulatory protein that controls interaction
between actin & myosin
• 3 subunits: TnC, I, T
• Unique cardiac troponins I and T exist - absent in
serum of healthy people
• Powerful marker of myocyte damage
• Rise at 3-4 hours post-MI, peak 18-36 hrs,
decline slowly 10-14 days
Skeletal &Skeletal &cardiac musclecardiac muscle
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Creatinine KinaseCreatinine Kinase
• Enzyme that converts ADP to ATP
• Found in many tissues: heart, brain, skeletal muscle, kidney, etc.
• Can be elevated after injury to any of these tissues
• 3 isoenzymes: - CK-MM- CK-MB- CK-BB
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CPK-MBCPK-MB
• Makes up 1-3% of skeletal CK
• Makes up much higher % of cardiac CK
• Rises 4-8 hours after MI, peaks by 24 hours
• Returns to normal in 48-72 hours
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Treatment of AcuteTreatment of Acute
Coronary Syndromes:Coronary Syndromes:
STE vs. Non STESTE vs. Non STE
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Treatment of Acute Coronary Treatment of Acute Coronary SyndromesSyndromes
• Anti-ischemic therapiesAnti-ischemic therapies
• General measures:General measures:
• Antithrombotic therapiesAntithrombotic therapiesAntiplatelet agents:Antiplatelet agents:
Anticoagulants (use one):Anticoagulants (use one):
• Adjunctive therapies:Adjunctive therapies:
• ΒΒ-blocker-blocker• NitratesNitrates• +/- Calcium channel blocker+/- Calcium channel blocker
• Pain control (morphine)Pain control (morphine)• Supplemental OSupplemental O22 if needed if needed
• AspirinAspirin• Clopidogrel (or prasugrel)Clopidogrel (or prasugrel)• GP IIb/IIIa inhibitor (for selected high GP IIb/IIIa inhibitor (for selected high
risk patients; may be deferred until PCI)risk patients; may be deferred until PCI)• LMWH (enoxaparin)LMWH (enoxaparin)• Unfractionated intravenous heparinUnfractionated intravenous heparin• FondaparinuxFondaparinux• Bivalirudin (should be used in ACS Bivalirudin (should be used in ACS
patient only if undergoing PCI)patient only if undergoing PCI)
• StatinStatin• Angiotensin converting-enzyme inhibitorAngiotensin converting-enzyme inhibitor
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Treatment of Acute Coronary Treatment of Acute Coronary SyndromesSyndromes
ST-Elevation(STEMI)
Emergent PCI availablewithin 90 min?
FibrinolyticTherapy
(e.g., tPA)
Non-ST-Elevation(UA and NSTEMI)
Risk Assessment(e.g., GRACE Score)
Primary PCI ConservativeStrategy
(Proceed to cardiac cathonly if recurrent angina
or predischargestress test is markedly
positive)
InvasiveStrategy
(Cardiac cathleading to
PCI or CABG)
No Yes Low High
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I
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Antithrombin RxAntithrombin Rx
Factor X
TF / VII a
Factor X a LMWH
V Ca++ UFH
Prothrombin Thrombin Hirudin
FibrinogenFibrin Clot
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NitratesNitrates
• Reduce ischemia (not mortality)
• Venodilation: R heart return
• Coronary vasodilation
• Usually given SL then IV
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Beta BlockersBeta Blockers
• Sympathetic drive; HR & BP
• O2 demand
• Shear stress
• Sudden death, death, recurrent MI
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Non DihydropyridineNon DihydropyridineCalcium Channel BlockersCalcium Channel Blockers
• Heart rate
• Vasodilate
• Relieve ischemia, not mortality
• Don’t give in patients with sx/signs
of heart failure
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Non - STE ACS:Non - STE ACS:
Conservative vs. EarlyConservative vs. Early
Invasive ApproachInvasive Approach
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Early InvasiveEarly Invasive
• Urgent catheterization performed after
initial medical Rx
• Allows rapid identification & Rx of
critical CAD
• More PCI/CABG
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ConservativeConservative
• Cath patients with recurrent ischemia
in hospital
• Cath patients with inducible ischemia
on pre-discharge stress test
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Invasive vs. ConservativeInvasive vs. Conservative
• Recent clinical trials show less infarction/reinfarction & possibly death with invasive strategy
• Especially in higher risk patients:
– ST segment deviation
– Elevated biomarkers
– Multiple risk factors… esp. DM
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Acute Treatment: STE MIAcute Treatment: STE MI
• Reperfusion: Thrombolysis vs. PTCA
• ASA
• O2
• Beta blockers
• Nitrates
• ACE inhibitors
• Morphine
• Anticoagulants
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AA
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 188
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BB
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 188
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75
2.5
6
10.05
6.88
97 6.8
21
2 1.1
5.3
14
0
5
10
15
20
25
PTCA
Lytics
PCI vs. LyticPCI vs. LyticShort-Term OutcomesShort-Term Outcomes
Fre
quen
cy (
%)
Fre
quen
cy (
%)
9.66.2 4.8
22
0 0 0
1212.88.7 10
39
0 0 0
19
0
10
20
30
40
50
Long-Term OutcomesLong-Term Outcomes
P=0.0002P=0.0002P=0.0003P=0.0003 P<0.0001P<0.0001
P<0.0001P<0.0001
P=0.0004P=0.0004 P<0.0001P<0.0001
P<0.032P<0.032
P<0.0001P<0.0001
P=0.0019P=0.0019P=0.0053P=0.0053 P<0.0001P<0.0001
P<0.0001P<0.0001
P<0.0001P<0.0001
DeathDeath DeathDeathExcludingExcludingSHOCKSHOCK
NonfatalNonfatalMIMI
RecurrentRecurrentIschemiaIschemia
TotalTotalCVACVA
Intra-Intra-CranialCranialBleedBleed
MajorMajorBleedBleed
Death/Death/CVA/MICVA/MI
CircCirc 2003; 107: 2538-2542 2003; 107: 2538-2542
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Additional Rx: STE MIAdditional Rx: STE MI
• Maintain vessel patency
• Restore balance between 02 supply
and demand
• Relieve chest pain
• Prevent complications
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AspirinAspirin
• Reduces mortality & reinfarction
• Give immediately on presentation
and daily thereafter
• If aspirin allergy, use clopidogrel
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HeparinHeparin
• Give 1-2 days IV after PCI or lysis with tPA, rPA, or TNK-tPA… NOT SK
• Also if:
– Atrial fibrillation
– LV thrombus
– New anterior MI with large wall motion change
• All others: SQ heparin while at bed rest to prevent DVT
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ß- Blockersß- Blockers
• Risk arrhythmia, reinfarction, rupture,
death
• Give IV, then orally unless
contraindication exists (asthma,
hypotension, significant bradycardia)
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NitratesNitrates
• Reduce pain/ischemia
• Relieve pain
• Reduce pulmonary congestion in
heart failure
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ACE - InhibitorsACE - Inhibitors
• Limit adverse LV remodeling
• Heart failure/death
• MI
• Benefit additive ASA, BB
• Esp. benefit anterior MI and/or LV
dysfunction
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StatinsStatins
• Reduce reinfarction, death
• More benefit when started early
• Give if LDL cholesterol is > 100
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Acute MI: ComplicationsAcute MI: Complications
• Recurrent ischemic/reinfarction
• Arrhythmias
• Myocardial dysfunction
• Mechanical complications
• Pericarditis
• Thromboembolism
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Complications of MIComplications of MIMyocardial InfarctionMyocardial Infarction
VentricularVentricularthrombusthrombus ContractilityContractility ElectricalElectrical
instabilityinstabilityTissueTissue
necrosisnecrosisPericardialPericardial
inflammationinflammation
EmbolismEmbolism ArrhythmiasArrhythmias PericarditisPericarditis
PapillaryPapillarymusclemuscle
infarction/infarction/ischemiaischemia
VentricularVentricularseptalseptaldefectdefect
VentricularVentricularrupturerupture
MitralMitralregurgitationregurgitation
CongestiveCongestiveheart failureheart failure
CoronaryCoronaryperfusionperfusionpressurepressure
IschemiaIschemia HypotensionHypotension
CardiogenicCardiogenicshockshock
CardiacCardiactamponadetamponade
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Recurrent IschemiaRecurrent Ischemia
• Angina or ischemia confers
increase risk for reinfarction
• Should lead to angiography and
revascularization for most pts.
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Arrhythmias in Acute MIArrhythmias in Acute MI
• Sinus Bradycardia - Vagal tone
- SA nodal artery perfusion
• Sinus Tachycardia - CHF
- Volume depletion- Pericarditis- Chronotrophic drugs (e.g.
Dopamine)
• APB’s, atrial fib, - CHF
VPB’s, VT, VF - Atrial Ischemia
- Ventricular ischemia- CHF
• AV block (1o, 2o, 3o) - IMI: Vagal tone and AV nodal artery flow
- AMI: Extensive destruction of conduction tissue
Rhythm Cause
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Blood Supply in theBlood Supply in theConduction SystemConduction System
• SA node - RCA (70% of patients)
• AV node - RCA (85% of patients)
• Bundle of His - LAD (septal branches)
• RBB - Proximal portion by LAD
- Distal portion by RCA
• LBB
Left anterior fascicle - LAD
Left posterior fascicle - LAD and PDA
Conduction Pathway Primary Arterial Supply
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Myocardial DysfunctionMyocardial Dysfunction
• Congestive Heart Failure
– Systolic or diastolic
– Treated with vasodilators, diuretics, and Rx to reverse ischemia
• Cardiogenic Shock
– Depressed CO
– Hypotension
– Poor perfusion of vital organs
– Treatment: Look/Treat reversible cause
– Inotropes/vasodilators/IABP
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Cardiogenic Shock - MI - 1YCardiogenic Shock - MI - 1Y
Initial Medical Stabilization - n=150Initial Medical Stabilization - n=150
Time From Randomization, moTime From Randomization, mo
Pro
port
ion
Aliv
eP
ropo
rtio
n A
live
00
Early Revascularization - n=152Early Revascularization - n=152
Shock (JS Hochman et al.) Shock (JS Hochman et al.) JAMAJAMA 2001; 285:190 2001; 285:190
1.01.0
0.80.8
0.60.6
0.40.4
0.20.2
00
22 44 66 88 1010 1212
Benefit < 75 YearsBenefit < 75 Years
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RV InfarctionRV Infarction
• Common in IMI’s
• Sx/signs:
– Hypotension
– Increase RA Pressure
• Rx:
– Volume, hemodynamic monitoring…PA line
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Papillary Muscle InfarctionPapillary Muscle Infarction
• “Common” in inferoposterior MI
• Leads to acute mitral valve
regurgitation
• Left heart failure/pulmonary edema
• Rx: Coronary revascularization;
IABP; valve repair
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Free Wall RuptureFree Wall Rupture
• More likely in elderly, HTN, women
• Usually rapidly fatal
• Occasional walls off to form
pseudoaneurysm
• Urgent surgery is best chance
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Ventricular Septal DefectVentricular Septal Defect
• Heralded by left to right shunting at
ventricular level
• RV volume overload
• Loud systolic murmur over sternum
• Usually requires surgical repair
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True Ventricular AneurysmTrue Ventricular Aneurysm
• Occurs late
• More often in non-reperfused STE
MI’s
• Complications: Clot, CHF,
arrhythmias
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PericarditisPericarditis
• More common in non-reperfused STE MI
• Fever, sharp pain with pleuritic tendency,
friction rub
• Treatment: nonsteroidal anti-inflammatory
agent; heparin relatively contraindicated
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ThromboembolismThromboembolism
• Clot forms on infarcted akinetic
myocardium
• Most common in large anterior MI
• Can cause embolic stroke
• Rx: 3-6 months anticoagulants
• If clot seen on echo or LVEF < 30% or if
large anterior MI
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Predictor of
Poor Outcome Method to Detect Treatment
Poor LVEF Echocardiogram ACE, BB
Residual Ischemia Pre D/C ETT Cath; ASA,BB
Max ETT later
Arrhythmias Monitoring/ Directed
Observation
Post MI Risk StratificationPost MI Risk Stratificationand Managementand Management
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Standard Discharge RxStandard Discharge Rx• 3 to 5 day length of stay• ASA; clopidogrel• Beta blocker• ACE for CHF; LVEF < 40%, perhaps all• Warfarin as noted• Cardiac Rehab• PRN Nitrates• Exercise prescription• Low fat diet• Smoking Cessation• Statin if LDL cholesterol > 100 mg/dl
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Kaplan–Meier Cumulative RiskKaplan–Meier Cumulative Riskof the Primary Outcome, Stratifiedof the Primary Outcome, Stratified
According to GRACE Risk Score at BaselineAccording to GRACE Risk Score at Baseline
Mehta SR Mehta SR et al. NEJM NEJM 2009;360:21722009;360:2172.