Myocardial Infarction 2

7/25/2019 Myocardial Infarction 2

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Myocardial infarction and unstable angina

Myocardial infarction (or heart attack) occurs from the blockage of one or several coronary

arteries. Coronary arteries supply the heart with oxygenated blood. Artery blockage occurs when anatheromatous plaque within the artery ruptures and forms a thrombus (blood clot) around it.

Atheromatous plaques and thrombus will obstruct the blood flow to myocardial cells depriving

them of oxygen and nutrients. !ithout blood supply heart muscle cells die. "f the heart is affected

during a large area of myocardium it can cause death. Myocardial infarction requires immediate therapy

to restore the blood flow.

Angina is a type of chest pain that occurs when the myocardial blood flow is not enough most

commonly occurs by decreasing the si#e of blood vessels (coronary arteries). $table angina appears after

a certain effort or after a physical activity.

%nstable angina appears as&

' a change in expression of stable angina

' a chest pain that occurs in rest or in a minor exercise chest pain can be severe and last longer or does

not respond to administration of nitroglycerin

' the occurrence of angina in a person who had not such events in history.

ecause unstable angina can progress to heart attack it requires immediate treatment.

Chest pain is not present in all cases. "n a recent study of *++ patients treated for myocardial

infarction ,*- were presented to the emergency room for other symptoms than chest pain. hese

symptoms were& dyspnea (breathing impaired) di##iness fatigue weakness or abdominal pain. !omen

diabetics or the elderly were feeling retrosternal pain in a lesser percent and more frequently than other

symptoms.

Protocol for myocardial infarction

"f a person suspects a heart attack and was prescribed nitroglycerin it is advisable to administer a

nitroglycerin pill. After / minutes if the pain does not respond or it is getting worse call the emergency

services.

"f there is a heart attack or unstable angina and weren0t prescribed nitroglycerin present to the

emergency room or call the ambulance. "t is important to start treatment quickly.

"f you can1t call the ambulance present to the emergency room. "t is not advisable to drive thecar in this state except if there are no other alternatives. 2o not wait to see if the symptoms will pass

because this option can be fatal.

3ach year about ,+- of myocardial infarctions are fatal and of which more than half of deaths

occur in the emergency room or before reaching the hospital.

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After you call the ambulance chew an aspirin. A recent study showed that those who were taking

aspirin during a heart attack after another month had a lower risk of dying because of complications due

to attack or stroke than those not taking aspirin.

%nstable angina can lead to heart attack or cardiac arrest (heart stopping). "n case of suspicion of

unstable angina there are recommended the same measures as for myocardial infarction.

Causes

he main cause of both unstable angina and myocardial infarction is coronary artery disease.

Coronary heart disease occurs when atheromatous plaques appear along the internal walls of the

coronary arteries and thus reduces blood flow to the heart. he ma4ority of coronary heart disease begins

in adolescence and develops over the years.

3levated cholesterol hypertension smoking and damaged arteries contribute to plaque

formation. he process of forming plates is called atherosclerosis. Are plaque deposits of cholesterol

calcium and other substances covered by a fibrous capsule5 "f you experience a sudden disturbance in

blood pressure the artery will contract suddenly but if other factors are present (as inflammation)

fibrous capsule of the plaque may break or crack.

he body will try to repair that crack in the same way as a skin lesion will repair by forming a

thrombus on the surface of the capsule. 6ormed thrombus may completely obstruct the artery blocking

blood flow to heart muscle and thus cause heart attacks. 7ewly formed plaque has the highest risk of

rupture. 6ibrous capsule of a newly formed plaque is more likely to break or crack (more unstable) than

an older thicker capsule plaque.

8laques are not always a reason for myocardial infarction. "n some cases rarely coronary spasm

and contracture can completely obstruct blood flow and cause heart attacks. Most often in these casesall atherosclerosis is involved but there are cases in which other factors produce spasm. Cocaine cold

weather emotional stress can cause episodes of arterial spasm. "n many other cases it is unknown the

cause of these spasms.

hrombus formed on a ruptured or fissured plaque may not be large enough to block the artery

completely but can decrease blood flow in that artery vascular territory causing unstable angina.

%nstable angina may be a sign that would follow a heart attack because that thrombus may grow in si#e

and completely artery obstruction. "f the thrombus is dissolved a heart attack will soon be avoided and

the body will try over time to repair the damaged capsule plaque. Also a freshly repaired plaque can be

unstable. he probability of rupture is high again making it an important risk factor for a new heart

attack.

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Precipitating factors

"n many cases it is not known certainly which are the causes of a heart attack.

$ometimes the body releases adrenaline and other hormones into the bloodstream in response tosome intense emotions like anger fear.

8hysical exertion emotional stress sleep deprivation and overnutrition can also be precipitating

factors. Adrenaline increases heart rate and blood pressure and coronary spasm can cause things that can

cause the rupture of unstable plaques.

Cocaine and nicotine which can be found in tobacco products can produce similar effects.

Symptoms

Most common symptom of heart attack is severe chest pain although this feeling is not alwayspresent.

"n some cases silent myocardial infarction occurs without symptoms but this is rare.

Most people with retrosternal pain and heart attacks have at least one of the following symptoms&

' $hortness of breath throat foreign body and always feel the need to swallow

' Cold sweats

' nausea

' $ensation of imminent death

' $hortness of breath or inability to breathe

' 8alpitations or feeling that the heart beats rapidly and irregularly (palpitations are a common symptom

in healthy people too but they can signal a coronary artery disease)

' 7umbness or discomfort in the hand or arm.

8eople who have had myocardial infarction described the chest pain in several ways.

8ain can be described in the following forms&

' 6eeling of pressure weight pressing squee#ing discomfort burning sharp pain (less common) or

confusing pain people usually put his fiston his chest when asked to describe the pain

' Can radiate from the chest in the left shoulder and left hand (most common site of irradiation) or in

other regions including the back upper abdomen and right hand

' Can be scattered the exact location of pain is usually difficult to determine

' 2oes not improve by a forced breath or chest tightness

' %sually starts with a low intensity and increases in intensity over several minutes to a maximum.

2iscomfort may be intermittent. Chest pain that reaches maximum intensity within seconds can be a

sign of another disease aneurysm of aorta.

"ndicated call to emergency services when&

' Chest pain worsens or does not disappear during / minutes especially if associated with impaired

breathing nausea or impaired consciousness

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' Chest pain does not improve or worsens within a / minutes after administration of netroglicerina.

he difference between unstable angina and myocardial infarction may not be always easy. he

symptoms are often similar. oth conditions require emergency treatment.

8eople who have unstable angina pain were described with the following characteristics&

' 2ebut in the last two months and rising over time

' 6requency of pain of 9 or more times per day

' $uddenly increases its intensity becomes more frequent lasts longer and is caused by a lower activity

than in the past

' :ccurs when resting without being precipitated by exercise or stress may awaken the person from

sleep

' 2oes not respond to nitroglycerin.

$table angina symptoms are different from those of unstable angina. $table angina occurs in a

predictable time after a particular exercise or activity and may have the same character over a long

period of time even years. 8ain is relieved by rest or nitroglycerin administration and lasts at least ;+'9+

minutes.

Risk Factors

Coronary heart disease is the leading cause of myocardial infarction in all nearly cases. herefore

the more risk factors there are for coronary artery disease the greater will be the risk of unstable angina

or myocardial infarction. $moking diabetes high cholesterol hypertension and a family history of heart

disease are important factors for coronary artery disease.

3ven if coronary disease is already present or there is a history of myocardial infarction the risk of

developing a heart attack can be diminished.o reduce risks are indicated&

' $top smoking& $topping smoking is probably the most important step to decrease the risk of a heart

attack

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' reatment of depression and emotion control& treatment of depression and emotional disorders are

important steps in improving cardiac function and quality of life

' evels of homocysteine and a specific gene mutation may also increase the risk of heart attackalthough more studies are needed to fully understand the role of these factors in heart disease. $ome

tests to highlight these risk factors may be necessary in some people especially those who had a heart

attack at young age but are not recommended for daily use.

?igh levels of C'reactive protein a substance found in blood that indicates inflammation may

have a greater predictive value for heart attack than cholesterol levels. wo studies based on C'reactive

protein levels and treatment with statins have shown that C'reactive protein levels may predict risk of

heart attack even when the person has normal or low levels of >2>'cholesterol. $tudies have shown

that both C'reactive protein test and cholesterol can prevent a greater extent in heart attacks.

Call a Doctor

3mergency presentation to the doctor is indicated when one of the following signs of heart attack

are present&

' Chest pain that does not improve or gets worse within / minutes after administration of nitroglycerin

and @ or rest after his rescue call it will also be given a nitroglycerin if it does not reduce chest pain in /

minutes is will be given one more nitroglycerin (can manage up to three doses of nitroglycerin to /

minutes or up to 9 doses in / minutes) after he called emergency call will continue to receive

instructions from the controller

' Chest pain or discomfort that is annoying and appears as a feeling of pressure on the chest that gets

worse or lasts more than five minutes especially if associated with&

' sweating

' reathing disorders

' 7ausea or vomiting

' 8ain that radiates to the neck 4aw in one or both shoulders or arms

' di##iness

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' "rregular pulse fast.

After you call the ambulance is advisable to chew an aspirin unless the cases when the aspirin is

contraindicated for example allergies to aspirin or gastric ulcer.

"n that they go by ambulance to the hospital treatment will begin again during the road and the

ambulance staff is trained for providing first aid evaluation and treatment if complications arise.

"f a person becomes unconscious will call the emergency and begin C8


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since the emergency room to assess whether the risk of heart attack is high. "f the $83C test is

abnormal the patient will be considered high risk and will require cardiac catheteri#ation.

"f the test does not indicate a heart attack but the doctor thinks it is an unstable angina the

patient will be hospitali#ed for monitoring.

Investigations conducted after heart attack

After ;'9 days of hospitali#ation after heart attack or hospitali#ed for unstable angina further

investigation will be conducted to assess how well the heart works and to determine whether unaffected

heart areas are suitable infusioned.

hese tests include&

' Cardiac ultrasound& this is an investigation that evaluates the si#e thickness shape and movement of

the heart muscles it also assesses the flow of blood and heart valves

' $tress 3lectrocardiogram& a stress test will compare the 3C during the rest period with the one after

stressing the heart either through physical activity (biking or climbing stairs) or by using drugs a stress

test will detect ischemiawhich represents the reducing of the blood flow to the myocardium

' $tress echocardiography& it determines whether there is reduced blood flow to the heart

' ?eart perfusion scan& scanning with thallium or technetium is used to estimate the amount of blood

reaching the myocardium at rest and after exercise

' Angiogram& his test involves in4ecting a contrast agent in order to assess coronary heart and coronary

arteries.

reatment

"n case of a heart attack in progress it is necessary to intervene immediately.

8rompt treatment with drugs angioplasty combined with stents installation or surgical

procedures to restore blood flow after the onset of symptoms may prevent permanent damage to the

myocardium and may save your life.

Initial treatment

he goal of therapy during a heart attack is to prevent permanent damage by restoring blood flowto heart muscles as quickly as possible. 2uring transport to hospital by ambulance will be given oxygen

nitroglycerin and probably a strong painkiller like morphine. "n addition may be given aspirin heparin

or other antiplatelet agents to prevent the increase in si#e of thrombi. :ther drugs may be administered

to reduce cardiac labor improve heart pump function and prevent abnormal heart rhythms that can be

fatal.

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ime until reaching the hospital is very important because angioplasty and @ or the assembly of

stents to open blocked arteries and thrombolysis lumen which dissolve thrombi are more effective in the

early hours of the onset of symptoms. hrombolytics are administered intravenously and will flow

through blood to the level of the coronary arteries where they will dissolve the thrombi.

7umerous studies have shown that angioplasty with or without a stent installation save about ;+

lives for every +++ patients treated compared to treatment with thrombolytics. Although angioplasty

with or without a stent mounting is the preferred therapeutic procedure it is not available in all hospitals

and needs to be done in the first ; hours after the onset of symptoms. "t is therefore important that the

ambulance personnel to recogni#e a heart attack and transport the patient to the nearest center that has

the means to intervene in these cases even if it will go to the nearest hospital.

"f the treatment is done in a hospital that has the necessary facilities for such cases the patient

will undergo a cardiac catheteri#ation and angioplasty indicate determine whether or coronary bypass

surgery. "f angioplasty with or without stent mounting is not possible either because the location of the

blockage or due to a larger number of blocks will help you do a surgery and coronary bypass.

"n the case of unstable angina treatment consists of hospitali#ation and administration of aspirinheparin or other antiplatelet agents (drugs that prevent formation of thrombi). he patient will be closely

monitored and will perform various tests. "f symptoms do not resolve after initial treatment and the risk

of heart attack is considered high there will be a coronary catheteri#ation and angioplasty probably

install a stent to prevent heart attack.

!ngoing treatment

After a heart attack patient will be hospitali#ed for at least several days they will be monitored&

heart rate blood pressure effects of drugs. $hall be made in this period several 3DEs(electrocardiografii). Monitoring after heart attack is necessary because during the next attack are

common complications such as potentially fatal arrhythmias or heart failure.

Medicines used to prevent complications agents will be administered fairly quickly after heart

attack. Angiotensin inhibitors and beta'blockers can prevent heart failure and arrhythmias (abnormal

heart beats). 2rugs that lower cholesterol levels (statins) are given for lowering the >2>'cholesterol (a

formation of atherogenic cholesterol) below *+ milligrams @ deciliter or lower amount.

A recent study on a large number of patients demonstrated that administration of drugs that

lower cholesterol levels reduce the risk of heart attack in a period of five years in people at high risk eg

those who have had a heart attack in history.

Aspirin and other antiplatelet drugs such as clopidogrel or ticlopidine can be administered after a

heart attack. hese drugs reduce the risk of a heart attack and prevent the formation of thrombi in the

cavities of the heart the clot can break off and can get into the brain causing a stroke.

he proportion of irreversibly damaged heart tissue may be lower than expected after a heart

attack. Certain portions of the myocardium may be affected temporarily they will not shrink but in time

they can resume function. ?eart pump function will be closely monitored and treatment will be ad4usted

as needed during this period.

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aughter of developing these complications depends on the damaged myocardial tissue during

heart attack and taking drugs to prevent them. :ther factors such as age and health can also influence

the risk of complications or death.

After a heart attack it is indicated for patients to participate in a rehabilitation program to reduce

death risks due to heart disease.


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Aspirin

Mode of action

Aspirin takes effect rapidly (approximately in / minutes) and prevents thrombus formation

reduces the risk of heart attack or stroke. All types of aspirin are equally effective.

Indications

Aspirin may be given&

' 2uring a heart attack in which case it will be chewed (do not swallow it entirely)

' "n people with stable angina

' he treatment of unstable angina

' "n people with heart disease to reduce the risk of heart attack

' "n people older than /+ years healthy but have one or more risk factors for cardiovascular disease

' After bypass or angioplasty surgery

' o people who have had a stroke a transient ischemic attack or had undergone a surgery to prevent a

stroke (carotid endarterectomy).Effectiveness

$tudies have shown that people who have an increased risk of coronary artery disease or who

already have coronary heart disease benefit most from this therapy. A recent study showed that in people

older than =/ years with heart failure and coronary heart disease death rate is significantly lower if

aspirin is taken regularly.

Aspirin may reduce symptoms in unstable angina.

"n people with low risk of cardiovascular disease the benefits of aspirin therapy may be

exceeded by the increased risk of bleeding present in this therapy.

Side effects

$ide effects of aspirin include&' astritis (inflammation of the gastric mucosa)

' astrointestinal bleeding

' Allergic reactions

' "ncreased frequency of hematomas (blood clots) and bleeding in the brain or other internal organs.

Note!

$ome doctors believe that people who have one or more risk factors for coronary artery disease

should take aspirin every day. :thers believe that taking daily aspirin for a long time increases the risk

of disease or stomach bleeding if hypertension is associated and it is not treated.

3xperts recommend the administration of the */'=+ mg of aspirin per day. Aspirin tablets on the

market are /++ mg. "t is advisable to call your doctor before starting daily aspirin administration.

ecause aspirin reduces the ability to form blood clots its administration can be discontinued at

least / days before surgery or dental procedure that involves bleeding.


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at least ; hours before taking non'steroidal anti'inflammatory to reduce the likelihood that the two drug

agents to interact.

Other antiplatelet

3xamples of platelet aggregation&

' Clopidogrel (8lavix)

' iclopidine (iclid).

Mode of action

hese drugs agents work in several ways to prevent formation of thrombi (blood clots).

Indications

Antiplatelet medication is used in people with unstable angina or heart attack and those with

angina who underwent angioplasty.

iclopidine and clopidogrel are administered to people who can1t take aspirin or for whom

aspirin is not sufficient to prevent thrombus formation. hese drugs are administrated at least for a

month in some cases even more after mounting stents on coronary arteries. hese drugs are used in

combination with aspirin to prevent clots in arteries that have stents.

Effectiveness

iclopidine or clopidogrel reduce the risk of a heart attack or stroke than aspirin alone more

effective in people with coronary artery disease. A recent study showed that taking aspirin in

combination with copidogrel in patients with unstable angina or heart attack reduces the risk of death

the occurrence of another heart attack or stroke in ;+- of cases.

"f that is administered after angioplasty a recent study showed that clopidogrel administration

before surgery and continuing for another eight months reduced the risk of death or another heart attackin about a third of the patients compared with administration on a shorter period (, weeks).

Side effects

$ide effects of platelet aggregation are&

' "ntracerebral hemorrhage or other organs

' leeding of the stomach or intestines

' ruises that appear frequently

' astric irritation

' Allergic reactions

' hrombocytopenia (low platelet count) low number of white blood cells (neutropenia) low number of

red blood cells (anemia).

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Note!

All agencies with a role antiplatelet drug increases the risk of bleeding.

Anticoagulants

' ?eparin

' 3noxaparin (>evenox)

' 2eltaparin (6ragmin).

Nitrates (nitroglycerin)

$ome medicinal agents that reduce cardiac labor improve blood flow to the heart and relievechest pain are given to individuals with unstable angina who are at risk of heart attack. hese drugs

include nitrates (nitroglycerin).

3xamples of nitrates&

' 7itroglycerin

' "sosorbit dinitrate

' "sosorbine moninitrat.

7itrates are in the form of pills or spray that is sublingual sprayed. hey can also take the form

of patches or paste that is applied to the skin. "n emergencies such as during a heart attack nitrates will

be administered intravenously.

Mode of action7itrates dilate coronary arteries increase blood flow relieve pain and reduce labor chest heart.

Indications

7itrates prevent and treat angina. hey can be used&

' 2uring episodes of angina

' efore activities that can cause angina (sexual activity or climbing stairs)

' "n long'term administration to prevent angina that occurs in daily activities.

6orms of sublingual administration are useful to treat episodes of angina. 8ills or patches that

have long action are used to prevent retrosternal pain occurred during the daily activities.

Effectiveness

7itrates are useful in relieving the retrosternal pain but don0t reduce the risk of death in patients

with heart attack.

Advantages of nitroglycerin

' Act fast

' "s easily managed either sublingually or intravenously

' he effects disappear within ;, hours.

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Side effects

$ide effects of nitrates are&

' 6eeling a pulsation or congestion in the head (the most common adverse effect) or headache

' $udden drop in blood pressure that can cause a feeling of di##iness

' $ublingual burning (in sublingual administration).

NoteG

2ifferent types of nitrates are often given in combinations. ablets patches or paste can be

managed with sublingual nitroglycerin to relieve and prevent angina. $ome people develop a tolerance

to nitrates when they are administered consistently and over a long period of time. olerance occurs

when drugs lose their effectiveness and seems to have no effect. Four doctor may indicate a time of

nitroglycerin administration for example it would be administered ;'H hours and ='; hours will not

be covered to prevent the nitroglycerin tolerance.

"f the patient continues to have episodes of angina despite the medication (beta'blockers or

calcium channel blockers) at the treatment it will be added long lasting nitroglycerin.

3ven if the pain releases after the administration of nitroglycerin the patient will have to go tothe doctor. "f angina episodes are becoming more frequent and last longer it is necessary to call your

doctor to ad4ust medication.

"f nitroglycerin compounds are old or almost at the end of validity it is probably that they have

not an adequate effect. ablets should be changed at every 9'= months.

8otency enhancement drugs are contraindicated (Iiagra) in people who are under the

administration of nitroglycerin. he combination of these two substances can cause a sudden drop in

blood pressure sometimes life'threatening. "n case the potency enhancement substances were

administered and an episode of angina occurs it is indicated to consult a doctor and to mention the

substances administered to prevent making a nitrate therapy.

Beta-blockers

Examples of beta-blockers:

' Atenolol

' Metoprolol

' acebutolol

' Carvedilol

' >abetalol

' propranolol' imolol

' 8enbutolol

' 8indolol.

Mode of action

he body responds to stress after a heart attack or unstable angina by increasing heart rate and

blood pressure. eta'blockers slow the heart rate and reduce labor.

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Indications

eta'blockers reduce heart rate blood pressure and heart labor. "f heart labor is low myocardium

will require less oxygen to function. eta'blockers are used in combination with other medications to

treat heart attack in progress.

Effectiveness

eta'blockers given within hours of the onset of a heart attack reduce the risk of death and

recurrence of the attack.

Side effects

Adverse effects of beta'blockers are&

' 6atigue di##iness and insomnia feeling

' "mpotence (erectile disorder)

' 2ecrease blood flow to the hands and feet which will cause a sensation of cold at these levels and

increased pain in the calfmuscle during physical activity (intermittent claudication)."n people with diabetes beta'blockers may increase blood sugar. hey can also cover the

symptoms of hypoglycemia such as the change in pulse.

NoteG

eta'blockers administered during and after a heart attack appear to reduce the risk of death.

$tudies have shown that beta'blockers should be administered at least = months after a heart attack in

order to have maximum benefits.

Administration of beta'blockers can interfere with other diseases. 6or example& astma heart

failure diabetes and certain types of arrytmias.

Administration of beta'blockers should be interrupted if these conditions will get worse or if

side effects occur and they can not be controlled. "n case of food allergies medications or insect bitesconcomitant administration of beta'blockers may worsen symptoms of these allergies and these will be

harder to treat.

2i##iness are more common in the early beta'blocker therapy or when doses increased. his

symptom can also be increased in combination with alcohol or after spending a long time in hot water. "t

is indicated that the rise from a lying position to make slow. "f disorders continues take a medical advice.

2o not suddenly stop taking beta'blockers. he risk of heart attack increases if beta'blockers are

stopped suddenly.

eta'blockers tend to diminish blood flow to the hands and feet and so they will be more

sensitive to low temperatures. "t is advisable to take several precautions such as thick dressing and avoid

spending a long period in cold weather.

Other therapeutic agents

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"n some cases can be used other therapeutic agents&

' "nhibitors of glycoprotein ""b @ """a which helps prevent thrombus formation in people with high risk

of heart attack or requiring angioplasty

' Calcium channel blockers which are given in cases where beta blockers are contraindicated

' Angiotensin converting en#yme inhibitors used to control blood pressure and reduce heart labor.

erape"tic agents "sed in eart attack

herapeutic agents used during heart attacks acts to restore blood flow more quickly and to

reduce heart labor.

o unblock arteries are used&

' Aspirin and other antiplatelet

' Anticoagulantii (heparin)

' "nhibitors of glycoprotein ""b @ """a (where angioplasty is needed)' hrombolytics.

rombolyticsdissolve trombiand other agents prevent their growth.

:xygen nitrates and beta'blockers act by decreasing heart labor and thus reduce the cantity of

oxygen needed myocardium.

herapeutic agents used after heart attack

After heart attack the administration of AC3 inhibitors and beta'blockers prevent the heart

failure and arrhythmias which can occur after a heart attack.Anticoagulants along with aspirin and other antiplatelet agents may be used after stroke to

prevent thrombus formation in the heart cavities and stroke.

eta'blockers AC3 inhibitors and drugs that lower the cholesterol levels (statins) are important

in preventing a heart attack.

After installing a stent to dilate an artery the doctor will indicate the administration of

clopidogrel. his drug prevents stent blockage due to a clot.

7itrates can be used to control symptoms of angina


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Surgery

"n some occasions surgical procedures involving coronary artery bypass is performed in

conditions of emergency treatment for heart attack. he coronary bypass is performed when the heart

attack can be effectively treated by drug therapy or angioplasty procedures.

6or example you will perform coronary bypass if the blockage is at the level of an artery that

can not be addressed by angioplasty or in cases where angioplasty was performed but results were not

satisfactory.

Also bypass procedures are recommended in patients with diabetes. $tudies have shown that

coronary bypass reduces death rate in patients with diabetes and heart attack compared to those treated

with angioplasty or thrombolytic therapy.

Note!

"n cases where after the heart attack was affected also the heart valves muscles (muscles that

keep the valves in position) will make repairations or replacements of the valves during surgery for

coronary bypass.

!ther treatments

"n the last decade angioplasty which is also called percutaneous coronary intervention has

become the most appropriate therapeutic procedure to treat heart attacks. Angioplasty is done during

cardiac catheterisation or coronary angiogram.

$tudies have shown that angioplasty with a stent assembly reduces the risk of recurrence of

artery narrowing and perhaps reduce the risk of death compared to angioplasty without stent assembly.Angioplasty with stent installing process is a less invasive procedure than bypass surgery and is the

preferred therapy for most patients with heart attack.

"n some cases a heart attack cause damage to large areas of the myocardium so that will be

affected the ability of the heart pump. 6or these cases we recommend to place a pacemaker (device that

stimulates the heart) this therapeutic procedure is recommended especially in patients with abnormal

heart rhythm.

Note!

3ven after stents installation the diameter of coronary arteries can narrow although the materials

and methods used in the last period increased long'term success rate of angioplasty with stent mounting.

Although study results are inconclusive it is assumed that treatment with folate (folic acid

combinations vitamin = and vitamin ;) is harmful after installing the stents and probably will be

avoided. "nstead of taking nutritional supplements containing vitamins it must be chosen a proper diet

which contain optimal amounts of these vitamins.

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Mortality after heart attack

Although treatment of heart attack rate is becoming more successful in prolonging life and

reducing complications there are cases in which stroke can cause fatal progressive disease like heart

failure or arrhythmias. 2ecisions regarding the fatal situations should be taken since the time the person

is active and able to communicate with others.

After diagnosis of a heart attack your doctor will determine the possible treatment options.

Cardiovascular resuscitation will be taken if it is the case or it will be useing aggressive methods to

maintain vital functions.

he decisions regarding a fatal situation must be taken before the begining of the situations that

can affect life as for example the writing of the will.

Prophyla#is

he number of heart attacks decreased in the recent years as the number of deaths from heart

attacks. his is largely due to measures taken to prevent coronary disease population such as

diminishing blood pressure serum cholesterol dietary changes and new habits including physical

activity.

he most important measures to be taken are stopping smoking and regular physical activity

performance. "t also recommended a diet rich in fruits and vegetables and low in saturated fat.

>ifestyle changes involve&

' $top smoking' Control of serum cholesterol

' Control blood pressure

' 8hysical activity

' Methods of relaxation and reducing stress

' Methods of therapy of depression and anger.

$ome doctors recommend a diet that includes vitamins such as = ; and folic acid. hese

vitamins reduce omocysteineserum levels (those with elevated homocysteine levels have an increased

risk of heart attack). "t hasn0t been certainly demonstrated if vitamin supplements prevent heart attack.

Most doctors recommend that vitamin should be taken from food and not as dietary supplements.

#olesterol

3levated serum cholesterol levels increase the risk of coronary heart disease. "f the diet and the

exercise will not achieve an optimal level of serum cholesterol your doctor will prescribe statins which

lower the cholesterol level. hese drugs have proven their efficacy in treating elevated cholesterol levels

and are currently widely prescribed by doctors worldwide.

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About half of patients who had a heart attack will develop a serious complication. he

compilation type depends on the location and extension of myocardial in4ury.

he most common complications are&

' Arrhythmias (abnormal heart rhythms)& can be ventricular tachycardia (rapid heart rate) and atrial

fibrillation (irregular heartbeat)

' ?eart failure which can be temporary or may be permanent.

Angina therapy

"f after a heart attack occur chest pain episodes or discomfort (angina) call immediate a doctor

because you may need aggressive treatment. hese episodes may indicate a new heart attack. $table

angina diminished under nitroglycerin treatment and at rest.

"t is recommended to always have on hand nitroglycerin tablets. $ome doctors recommendtaking nitroglycerin before physical activity to prevent episodes of angina.

$ifestyle after heart attack

$ome people seem restless after discharge and time spent in hospital may be too short. his

anxiety may be caused by lack of supervision by trained personnel. "nvestigations carried out before

leaving the hospital were the doctor who indicated that he was sure that the patient can continue anormal life.

o reduce the risk of a heart attack your doctor may recommend&

' $top smoking may be the most important step in reducing the risk there is evidence that people with

coronary disease who do not smoke reduces the risk of recurrent heart attack or death

' 2aily administration of aspirin or antiplatelet medication another if aspirin is contraindicated

' >owering serum cholesterol levels with drugs such as statins or other drugs that lower serum

cholesterol level

' Control blood pressure with prescription drugs certain nutrients in the diet can influence blood

pressure

' 2iet that includes fish in large quantity the fish diets may be useful in weight loss decreased blood

pressure and cholesterol

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' 2rinking alcohol in moderation ('; glasses of wine a day maximum) decreases the risk of

complications from a heart attack in a recent study middle'aged men alcohol consumption in amounts

moderate to significant reductions in complications associated with a period of four years some

associates say that is not proven link between wine consumption and reduce the severity of coronary

artery disease

' Affection to loved ones a person who had a heart attack may be scared and depression can be

common in these individuals. $upport loved ones can avoid depression. "f the emotional state does not

improve after stroke is important to call your doctor about it. A recent study showed that people who

have been treated for depression after heart attack had a better recovery than those who were not treated

(long'term survival but not affected).

efore beginning physical activity after a heart attack is indicated for the doctor to perform

certain tests to determine the risk of a heart attack.

:ne of the most common myths that refer to sexual activity would cause a heart attack a stroke

or death. According to medical recommendations sexual activity can be resumed whenever the patient

feels able to do so.

Medical specialists recommend

' 3mergency doctor& will assess and treat stroke in the emergency room

' Cardiologist& for outpatient treatment

' Cardiovascular surgeon& "f you require surgery.

Evolution and healing heart

"n ordinary cases when blood flow that remaines in coronary arteries is good healing begins

quickly. he portion of heart muscle that has suffered permanent damage will be replaced by a scar.

Myocardial infarction can leave some se%"elae which are variable and depend on&

K infarct si#e

K if it is a first heart attack or a relapse

K status of completely coronary artery.

$equelae may be minimal in the following cases& many patients agree to stop smoking to

exercise lose weight and after a few months after stroke recover very well.here is also possibility of sequelae&

K heart failure that causes difficulty breathing

K persistence of angina pectoris

K the occurrence of cardiac arrhythmias.

hese problems must be identified as quickly as possible ' their appearance after a heart attack

must guide you to your cardiologist doctorG 2epending on the results it will adapt the treatment.

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Convalescence and rehabilitation

3ach person recovering from acute myocardial infarction has two main purposes&

K developing a recovery plan for its capacity to live a life as close to normal

K Control risk factors that can reduce stroke recurrence.

"n the absence of complications patients should not stay in bed more than ; hours. 2aily

activity should be resumed gradually individually depending on overall condition age and physical

ability of the patient.

Stage & 'days &-()

2uring the first day the patient stay in bed being able to feed themselves using a table'support.

?e will receive full support for toilet. !ith help will perform passive movements of the arms and legs.

"n the next day the patient may sit on the bed or a chair for '; hours a day. ?e (she) is able toactively move hands @ feet for /'+ minutes a day.

Stage ( 'days *-+)

8atient may make its toilet and may dreesed'up but keeping the sitting position. Fou can sit on a

chair or sofa as often as desired and can walk through the room.

:n the fourth day the patient can take a shower or sitting upright (use a chair to reduce anxiety

and fear of falling).


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.ecommendations at discarge

"nitially it is important to avoid physical exertion lifting to rest several times a day. :ver time

you can do more activities and depending on how you support them.

Fou should avoid any activity that will produce anginal chest painG

"t is important to always have on hand nitroglycerin tablets which use them if necessary.

A long'term plan will include ways to reduce risk factors that could lead to recurrence of

myocardial infarction.

"t is essential to stopping smokingG "n patients who do not smoke over the coming years

significantly decreases the risk of heart disease.

8roper diet is also important. "t includes decreased intake of fat and cholesterol. 6irst you have

reduced fat intake from meat and dairy. Adding fruits and vegetables to food is good. "n some cases

lower blood cholesterol requires the use of drugs. "n hypertensive patients should be reduced while the

use of salt.

3xercise and physical activity in general is an extremely important factor for recovery frommyocardial infarction. "t is important to ask your doctor about the level of exercise that you can achieve.

Fou will be linked with cardiac rehabilitation specialists who will guide this. %nder their supervision

the cardiac rehabilitation department your physical activity will be monitored and guided to a better

physical recovery. 2iscuss this with your doctor without your inhibitions.

$exual activity may be resumed only after a stress test at the hospital. "t is considered that sexual

activity can be resumed when the patient can climb two floors with no problems.

:ther key measures to be taken to decrease cardiovascular risk in the future are& control of

hypertension diabetes and dyslipidemia (if present) weight control and avoiding stress. After a heart

attack or angina condition is not enough to take drugs. hey can be ineffective if not fight against risk

factors& obesity smoking diabetes mellitus hypertension dyslipidemia sedentaryG2rug treatment you will receive at discharge should be followed long term. "t will contain

several classes of essential medicines which should not be interrupted without the doctor.

Any ad4ustment of dose or dosage regimen should be made only with the doctorG

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Contents

Myocardial infarction and unstable angina...................................................1

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Protocol for myocardial infarction.................................................................1

auses..........................................................................................................2

!ym"toms.....................................................................................................3

#is$ %actors...................................................................................................4all a &octor.................................................................................................5

'n(estigations...............................................................................................6

)(aluation of emergency *eart attac$.......................................................6

'n(estigations conducted after *eart attac$..............................................7

+reatment.....................................................................................................7

'nitial treatment.........................................................................................7

,ngoing treatment.....................................................................................8+reatment if t*e condition gets -orse........................................................9

Medications................................................................................................9

+*era"eutic agents used after *eart attac$.............................................15

!urgery....................................................................................................16

,t*er treatments.....................................................................................16

Mortality after *eart attac$......................................................................17

Pro"*ylais.................................................................................................17

/ifestyle after *eart attac$.........................................................................19

Medical s"ecialists recommend..................................................................20

)(olution and *ealing *eart........................................................................20

on(alescence and re*abilitation............................................................21

&isc*arge.................................................................................................21

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Myocardial Infarction 2

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Transcript of Myocardial Infarction 2