YOCARDIAL INFARCTION Infarct usually 2o to acute thrombosis or prolonged

vasospasm in an atherosclerotic vessel.

CARDIAC CATH 1. The gold standard for diagnosing CAD.

2. A long hollow tube, a catheter, can be threaded into an artery up into the heart.
3. Then material opaque to X-rays can be released into the blood flow through the
heart imaging the details of coronary arteries.
4. Typically used to identify a blockage and location in the coronary circulation FOR
TX.

PTCA: percutaneous transluminal coronary angioplasty A method of treating

narrowing of the coronary artery by inserting specialized catheter with a balloon
attachment, then inflating it to dilate and the narrow portion of the vessel and
restore blood flow to the myocardium; most often includes placement of a stent.
- MUST BE DONE WITHIN 90 MIN.

C/I to give ____ in a INFERIOR MI bc it decreased preload --> Hypotension. NITRATES.

RIGHT CORONARY ARTERY --> INFERIOR MI:

***
RIGHT CORONARY ARTERY --> INFERIOR MI:
1. LEADS:
2. A & V:
3. AREAS INVOLVED:

4.

- ORIGIN:
- COURSE:
- Branches: 1. STEMI IN II, III, aVF

2. RCA TRAVELS W/ Small cardiac vein

3.
- Right atrium: AV/SA NODES,
- Supplies inferior wall of heart -->
Right ventricle + 25-23% of L ventricle.
4.
- Originates above the R cusp of Arotic valve.
- Courses to the right side of the heart;
- Gives rise to
1. Right marginal artery
2. PAD: Posterior Descending Artery.

Posterior MI Posterior Descending Artery.

Look in V1-V2

***
Left circumflex ARTERY --> LATERAL MI 1. ST ELEVATION: Leads I, AVL, V5, V6
2. Left circumflex: LCxA : artery branches from LCA: left coronary artery
3. SUPPLIES:
- left atrial wall,

- lateral * posterior wall of the left ventricle

- The Sinus node 45% of the time.

CABG Coronary Arterial Bypass Graft

The most common cause of MI is an acute thrombus on a ruptured atherosclerotic

plaque.

MYOCARDIAL INFARCTION
- Si/Sx: KEY Si/SX -->
1. Acute onset, Substernal C.Pain/Pressure/ Tightness with Radiate to left arm, neck,
or jaw.
2. C. Pain NOT relieved by rest, position, or anything.
-/+ Si/Sx:
- Diaphoresis, Anxiety, N/V, TACHY/BRADY/ PVC
- SOB --> Light-headedness --> Syncope .

MYOCARDIAL INFARCTION
- Classic Triad: 1. Acute, substernal C.P. /Pressure/ Tightness
2. Radiate to the left arm, neck, or jaw
3. NOT relieved by rest.

A 68-year-old male presents with chest pain that started 4 hours ago. It is
accompanied by shortness of breath and diaphoresis. ECG shows sinus tachycardia
of 120 with multifocal PVCs, ST-segment elevation and a u wave. Laboratory
analysis is evident for Troponin I 3.1 ng/mL.
- DX: MYOCARDIAL INFARCTION
- chest pain > 15 min

- diaphoresis.
- tachycardia /multifocal PVCs/ST-segment elevation
- u wave
- Troponin I 3.1 ng/mL.: KEY!

***
u-wave is a/w - hypokalemia, hypercalcemia, hyperthyroidism
- EKG of hypokalemia

Diagnosis of MYOCARDIAL INFARCTION: 1. (+) Si/Sx:

2. *EKG
- ST elevation/ depression
- (+) Q waves: marker of ischemia
- New LBBB
3. Elevated Troponin I or CK-MB*:
- MB normalizes after 72hrs.
- Troponin remains elevated for up to 1 week( > 0.5)

MYOCARDIAL INFARCTION
- Sequence of ECG changes: PHASE-1:
1. Peaked T waves,
2. ST-segment elevation,
3. Q waves,
PHASE-2:
4. T-wave inversion
5. ST-segment normalization,

PHASE-3:
6. T-wave normalization.

***
Inferior wall (LV)MI: 1. ST-elevations in leads II, III, & aVF .
2. ST-DEPRESSION in lead 1 & aVL.
3. RCA is infarcted which supplies the right atrium, right ventricle, SA/AV nodes, &
25-23% of L ventricle.

***
LAD: Left Anterior Descending --> Anterior MI. 1. Anterior branch of LCA: left
coronary artery.

2. SUPPLIES:
a. anterior 2/3 of IV septum
b. anterior left ventricle: Primary source of blood
c. anterior papillary muscle

3. Leads:
- I, V2-V4

Left main coronary artery Subdivides into left anterior descending artery (LAD) and
circunflex coronary artery (LCx). Supply the more muscular left ventricle,
interventricular septum and part of the right ventricle. .

PICTURE Left main coronary artery --> LAD and LCxA


widow maker The Left Anterior Descending artery (LAD) is nicknamed the _____

PICTURE of coronary arteries

***
Most common blood vessel involved in myocardial infarction? Left Anterior
Descending Coronary Artery IN Anterior MI.

***
Anterior MI: 1. (+) ST-segment elevations in anterior leads (V1-V4)

2. Reciprocal changes:
- (+) ST- DEPRESSION IN II, III, & aVF .

3. INVOLVES LAD: Left Anterior Descending Artery ---> SUPPLIES

a. Anterior HRT: anterior Left ventricle.
b. of interventricular septum,
c. anterior papillary muscle,
d. bundle of his.

4. aka "Widow maker"

" WIDOW MAKER" MI is Anterior MI

Lateral MI Leads I, aVL, & V5-V6

***
1. ST-segment elevations in leads II, III, & aVF are consistent with an ____ MI.
2. ST-segment elevations in anterior leads (V1-V4) usually indicate an ____ MI.
3. ST-segment elevations in leads I, aVL, and V5-V6 indicate a ____ MI 1. inferior

2. anterior

3. lateral

***
Serial cardiac enzymes: 1. Troponin-I appears first & is most Sn & Sp.
2. CK-MB appears next lasts 72 hrs.

***
If tPA was used to lyse the clot, ____ should be given for 48hr post infarct. Heparin
(heparin has no proven benefit if streptokinase was used or if no lysis was
performed)

Candidate for PTCA: Discrete lesions in 1. Single-vessel disease.

or
2. Double-vessel disease.

MYOCARDIAL INFARCTION TREATMENT:

- Tx's GOAL: reestablish vessel patency:
1. Endovascular intervention:

2. Medical Tx:
3. Long-term Tx:
4. Adjuvant medical therapies:
5. Pain control: 1. Emergent angiography & revascularization with PTCA or CAGB
- PTCA more effective,can open vessels mechanically or with local administration of
thrombolytics.
- Indicated for single- or double-vessel disease with discrete lesions.
- Candidate for CABG: three-vessel disease, left main disease, discrete lesions not
amenable to PTCA, or diffuse disease.
2. If PTCA/CAGB is unavailable --> Thrombolysis with tPA (or urokinase, or
streptokinase) + Heparin (1st Line) within 6hr of the infarct.
3. Adjuvant Tx:
*#1 Priority is aspirin! (proven to mortality)
#2 Priority is -blocker (proven to mortality)
#3 Statins (LDL<100 s/p MI (proven to mortality)
#4. ACEI to control HTN: (proven to mortality)
5. O2 & morphine*

1st-line agents for HTN: thiazides.

Nitrate use and MI: - NOT USED FOR MI

- Nitrates are used for ANGINA & MALIGNANT HTN

Thrombolysis with tPA, urokinase, or streptokinase.

Risk of using a CCB Post-MI --> increases risk of another MI!

MYOCARDIAL INFARCTION:
1. Pain Control:
2. Reduce both pre- & afterloads:
3. ACE inhibitors:
4. Exercise: 1. O2 & morphine
2. BB:
- short & long term load reduction
- anti-arrythmic, antihypertensive
3. Excellent late & long-term therapy:
- afterload & prevent remodeling.
4. Strengthens heart, develops collateral vessels, HDL.

Benefits of Exercise: 1. Strengthens heart,

2. Develops collateral vessels,
3. HDL.

MYOCARDIAL INFARCTION:
- PE findings and indications: 1. Tachycardia, Bradycardia, Arrhythmias,
2. New mitral regurgitation
(ruptured papillary muscle),
3. Hypotension (cardiogenic shock),
4. Rales (pulmonary edema)
5. Ventricular fibrillation (20% of sudden deaths)

New mitral regurgitation in someone with a possible MI indicates: ruptured papillary

muscle.

Hypotension in someone with a possible MI indicates: cardiogenic shock.

Rales in someone with a possible MI indicates: pulmonary edema

20% of sudden deaths d/t MI are bc of Ventricular fibrillation

The best predictor of survival from a MI is left ventricular EF.

MOST LIKELY to have atypical, silent MIs: 1. Elderly,

2. Diabetic,
3. Postmenopausal
4. Post-orthotopic heart transplant patients

Indications for CABG- "DUST" D: Depressed Ventricular FXN

U: Unable to perform PTCA
S: Stenosis of Left Main
T: Triple-vessel disease.

Dressler's syndrome: An autoimmune process 2-4 weeks post-MI.

1. Fever, Leukocytosis, ESR
2. Pericarditis: (+) PLEURITIC CP, (+) FRICTION RUB
3. Pleural effusion

COMPLICATIONS of MI: 1. Reinfarction,

2. Ventricular wall/SEPTUM rupture, dilatation or aneurysm
4. Papillary muscle rupture (with mitral regurgitation),

5. Mural thrombi.
6. Pericarditis
7. Dressler's syndrome
8. Lethal arrhythmia is the most common cause of death following acute MI.

___ is the most common cause of death following acute MI. Lethal arrhythmia

POST MI within 4 days what could happen: Lethal arrhythmia

POST MI within 5-10 days what could happen: LV free wall rupture ---> Tamponade

POST MI within several weeks ( 3-5weeks) what could happen: 1. Ventricle

Aneurysm:
- LEFT sided CHF Si/Sx: rales, SOB, crackles
- ST elevation in V1-4
2. Dressler syndrome( 2-10 WEEKS S/P MI)
- Pericarditis w/ pleuritic CP, friction rub, WBC.
- NSAID--> better

Ventricular wall/SEPTUM rupture:

- OCCURS 4 -8 DAYS S/P myocardial infarction.
1. S/S:
2. CONFIRM DX WITH ___
3. TX: SURGERY. 1.
MAINLY Chest pain, Hypotension, and CHF.
1. (+) Harsh systolic murmur at left lower sternal border that radiates to the axilla
---> MIMICS MR!

2. CHF:
- Jugular venous distension and
- Crackles in both lung bases.
3. "STEP-UP SIGN" INCREASE BLOOD OXYGENATIOND/T VENTRICLE WALL RUPTURE
& LEFT TO RIGHT SHUNT.
- right atrium reveals an oxygen saturation of 45% while a sample from the right
ventricle reveals an oxygen saturation of 88%
2.
- ECHO
3.
- SURGERY.

"STEP-UP SIGN" INCREASE BLOOD OXYGENATION D/T VENTRICLE WALL RUPTURE &
LEFT TO RIGHT SHUNT.

A 58-year-old male patient is being evaluated for chest pain, hypotension, and
clinical decline.
- History reveals that he is on his fourth day in the intensive care unit after suffering
a myocardial infarction and was doing well until a few minutes prior.
- Vital signs reveal a blood pressure of 90/64 mmHg, a heart rate of 103/min, and a
respiratory rate of 18/min.
- Physical examination reveals a harsh systolic murmur heard best at the left lower
sternal border that radiates to the axilla. There is jugular venous distension and
crackles in both lung bases.
- A sample of blood from the right atrium reveals an oxygen saturation of 45% while
a sample from the right ventricle reveals an oxygen saturation of 88%.
- Laboratory studies reveal an elevated troponin and a normal CK-MB.
- The most likely diagnosis is DX: Ventricular wall/SEPTUM rupture:
- OCCURS 4 -8 DAYS S/P myocardial infarction.
- S/S: MAINLY Chest pain, Hypotension, and CHF.

1. (+) Harsh systolic murmur at left lower sternal border that radiates to the axilla
---> MIMICS MR!
2. CHF:
- Jugular venous distension and
- Crackles in both lung bases.
3. "STEP-UP SIGN" INCREASE BLOOD OXYGENATION.
- right atrium reveals an oxygen saturation of 45% while a sample from the right
ventricle reveals an oxygen saturation of 88%
- CONFIRM DX WITH ECHO
- TX: SURGERY.

POST MI within 1- week what could happen: Papillary Muscle Rupture

- Hypotension
- Pulmonary edema: SOB
- New systolic murmur.

NON-STEMI ---> (+) __, __, __, __. (+) CP

(+) TROPONIN
(+) ST Depression
(+) T-wave inversion

Stable Angina
1. lasts ____ minutes
2. Provoked with ____.
3. Relieved by __ or ___.
4. (+) ___ 1. 5-15min
2. excretion

3. rest or Nitroglycerin
4. ST depression