Q.

CORONARY ARTERY DISEASE (MYOCARDIAL

ISCHEMIA)
Discuss the clinical features, complications, investigations
and management of acute myocardial
infarction (ST elevation myocardial infarction-STEMI).

Acute Myocardial Infarction

• Myocardial infarction is myocardial necrosis occurring as
a result of a critical imbalance between coronary blood
supply and myocardial demand. It is usually due to the
formation of an occlusive thrombus at the site of rupture of
an atheromatous plaque in a coronary artery.

CLINICAL FEATURES
Symptoms
•Cardinal symptom is chest pain, but breathlessness,
syncope, vomiting and extreme tiredness are common.
Pain is at the
same site as for angina, but is more severe and prolonged.
It is severe, with pallor and a peculiar facial expression.
Pain is described as tightness, heaviness or constriction.
•Pain may be absent in patients with prior heart failure,
prior stroke, age >75 years, and diabetes mellitus.
Painless MI also more common in females compared to
males.
Signs
•Mild fever
•Pallor, sweating
•Tachycardia or bradycardia
•Arrhythmias
•Narrow pulse pressure
•Raised JVP
•Diffuse apical impulse
•Soft first heart sound
•Third heart sound
•Pericardia! friction rub
•Systolic murmur due to mitral regurgitation or
uncommonly due to VSD
•Basal crepitations
INVESTIGATIONS
Electrocardiogram
•Should be done and interpreted within 10 minutes of
arrival.
•ECG is useful in confirming the diagnosis. The typical
changes are seen in leads facing the infarcted area (e.g.
antero- septal, anterolateral, strict anterior, inferior and
posterior wall infarction).
Other Investigations
•Leucocytosis with a peak on 1st day.
•Raised ESR that may remain so for days.
•Elevated C-reactive protein.
•Chest radiography.
•Heart size is usually normal. Enlargement of cardiac
shadow may indicate previous myocardial damage or
pericardia! effusion.
•Evidence of pulmonary oedema.
•Radionuclide scanning shows the site of necrosis and the
extent of impairment of ventricular function.
•Echocardiography for regional wall motion abnormality
and ejection fraction.
MANAGEMENT
•In the first 24-48 hours when the risk of fatal arrhythmia is
highest, the patients are best treated in an intensive
coronary care unit.
Initial treatment
•Attach a cardiac monitor
•Secure an intravenous line
•Administer oxygen if oxygen saturation <94%
•Administer sublingual nitrate (if not taken by the patient
and pain is present)
•If no relief, give intravenous morphine 3-5 mg along with
an antiemetic. May repeat it 5-10 minutes after
the first dose
•Give aspirin 150 mg to be chewed
•Give clopidogrel 300-600 mg orally (unless coronary
artery bypass surgery is contemplated)
Confirm diagnosis
•ECG
•If available, troponin T or I and CK-MB
Specific therapy
•Thrombolysis or percutaneous coronary interventions
•13-blockers unless contraindicated
•Treat complications (arrhythmias, congestive failure and
shock)
•Admit in intensive coronary unit.