MYOCARDIAL INFARCTION

DEFINITION

• AN OCCLUSION OR SPASM IN THE CORONARY ARTERIES CAUSES MYOCARDIAL ISCHEMIA AND SUBSEQUENT MYOCARDIAL TISSUE
DEATH.

• THE MOST COMMON CAUSE IS ACUTE THROMBUS FORMATION ON A RUPTURED ATHEROSCLEROTIC PLAQUE.
• THE RISK FACTORS ARE THE SAME AS IN ISCHEMIC HEART DISEASE
 TYPES

• NSTEMI VS STEMI
• NSTEMI – MYOCARDIAL NECROSIS WITHOUT ACUTE ST-SEGMENT CHANGES.
• STEMI – MYOCARDIAL NECROSIS WITH ECG CHANGES SUCH AS ST-SEGMENT ELEVATION
• TRANSMURAL VS SUBENDOCARDIAL
• TRANSMURAL – INVOLVES THE WHOLE THICKNESS OF MYOCARDIUM FROM
• SUBENDOCARDIAL – USUALLY INVOLVES THE INNER ONE THIRD OF MYOCARDIUM
RISK FACTORS (MODIFIABLE)

• SMOKING
• DIABETES
• HYPERTENSION
• HYPERLIPIDEMIA
• OBESITY
• PHYSICAL INACTIVITY
RISK FACTORS (NON MODIFIABLE)

• AGE
• GENDER
• FAMILY HISTORY
 SYMPTOMS

• ACUTE-ONSET CHEST PAIN RADIATING TO THE LEFT ARM, JAW, NECK, AND SHOULDER

• SHORTNESS OF BREATH

• NAUSEA OR VOMITING
• DIAPHORESIS

• DIZZINESS

• BEWARE OF SILENT M.I,

• BIGGEST CONCERN IN THE ELDERLY, POST-MENOPAUSAL WOMEN, AND DIABETICS.

 PHYSICAL EXAM

• TACHYCARDIA

• NEW MITRAL REGURGITATION MURMUR DUE TO RUPTURED PAPILLARY MUSCLE

• S4 GALLOP
• HYPOTENSION
• SECONDARY TO CARDIOGENIC SHOCK FROM DECREASED CARDIAC OUTPUT
• CRACKLES
• FROM PULMONARY EDEMA
• CAUSED BY BACKFLOW AS A RESULT OF DECREASED CARDIAC OUTPUT
 EVALUATION

DIAGNOSIS MADE BY DEMONSTRATING AT LEAST 2 OUT OF 3 OF THE FOLLOWING

SIGNS, SYMPTOMS, AND RISK FACTORS:
• ST-ELEVATION OR ST-DEPRESSION
• REFLECTS TRANSMURAL ISCHEMIA OR SUBENDOTHELIAL ISCHEMIA, RESPECTIVELY.

• OCCURS WITHIN MINUTES AND RESOLVES AFTER 24-48 HOURS.

• T-WAVE INVERSION:
• REFLECTS TRANSMURAL INFARCTION

• OCCURS WITHIN HOURS, RETURNS TO UPRIGHT AFTER WEEKS.

• Q-WAVES
• REFLECT TRANSMURAL INFARCTION

• OCCUR WITHIN HOURS

• CAN BE A SIGN OF AN OLD INFARCTION
• NEW-ONSET LEFT BUNDLE BRANCH BLOCK

• POSITIVE CARDIAC ENZYMES

• TROPONIN IS STANDARD IN FIRST 8 HOURS

• CK-MB STANDARD IN THE FIRST 24 HOURS
• LDH1 IS BEST FOR 2-7 DAYS AFTER SYMPTOMS
• DIAGNOSIS OF RE-INFARCTION MADE IF CK-MB RISES FOUR DAYS AFTER THE INITIAL PRESENTATION
 TREATMENT

• ALL PATIENTS WITH SUSPECTED MI ARE TO BE:

• HOSPITALIZED IN CCU OR CARDIAC STEP-DOWN UNIT AND

• NOT TO BE DISCHARGED HOME UNTIL RULING OUT-MI

• 24-HR CARDIAC ENZYMES AND SERIAL EKGS

 ACUTE MANAGEMENT

• MORPHINE

• OXYGEN

• NITROGLYCERIN

• CONTRAINDICATED IN RIGHT INFERIOR WALL INFARCTION

• ACE INHIBITORS
• ASPIRIN

• BETA-BLOCKERS (IF NO HYPOTENSION, BRADYCARDIA, OR PULMONARY EDEMA)

• HEPARIN

• PERCUTANEOUS CORONARY INTERVENTION (PCI) SHOULD BE PERFORMED WITHIN 90 MINUTES FROM FIRST MEDICAL CONTACT
• IN THE FIRST 6-HOURS
• CAN USE THROMBOLYTICS (TPA)

• HEPARIN (GIVE 48 HRS POST-INFARCT IF TPA HAS BEEN USED TO LYSE THE CLOT)

• STREPTOKINASE

• FIVE DAYS FOLLOWING EPISODE

• IF STRESS TEST IS POSITIVE, THEN ORDER CARDIAC CATHERIZATION
 LONG TERM THERAPY (POST-MI)

• ASPIRIN

• BETA-BLOCKERS

• LIPID-LOWERING DRUGS

• HMG-COA REDUCTASE INHIBITORS DECREASE MORTALITY POST-MI

• ACEIS
• REDUCTION OF SOCIAL HABIT RISK FACTORS

• SMOKING CESSATION
• POTENTIALLY SCHEDULE FOR CABG OR STENTING PROCEDURES IF NEEDED

• DUAL ANTI-PLATELET THERAPY NEEDED S/P STENT PLACEMENT

 PROGNOSIS, PREVENTION, AND COMLICATIONS.

• TIME TO RESTORATION OF CORONARY BLOOD FLOW IS THE STRONGEST PREDICTOR OF LONG-TERM PROGNOSIS
• CARDIAC ARRYTHMIAS (90%) ARE THE MOST COMMON CAUSE OF DEATH
• LV FAILURE AND PULMONARY EDEMA (60%)
• THROMBOEMBOLISM
• CARDIOGENIC SHOCK
• VIA DECREASED CARDIAC OUTPUT
• VENTRICULAR WALL RUPTURE
• LEADING TO CARDIAC TAMPONADE IF PERICARDIUM INTACT
• OR MASSIVE INTRATHORACIC BLOOD LOSS AND DEATH
• PAPILLARY MUSCLE RUPTURE WITH MITRAL REGURGITATION
• FIBRINOUS PERICARDITIS
• RESULTS IN FRICTION RUB 3-5 DAYS POST MI

• DRESSLER'S SYNDROME
• AUTOIMMUNE DISEASE

• LEADS TO FIBRINOUS PERICARDITIS SEVERAL WEEKS POST-MI

 SUMMARY
• ACUTE M.I IS MYOCARDIAL NECROSIS RESULTING FROM ACUTE OBSTRUCTION OF A CORONARY ARTERY
• SY,MPTOMS OF ACUTE M.I INCLUDE CHEST PAIN OR DISCOMFORT WITH/WITHOUT DYSPNEA, NAUSEA &
DIAPHORESIS

• WOMEN AND DIABETIC PATIENTS ARE MORE LIKELY TO PRESENT WITH ATYPICAL SYMPTOMS, AND 20% OF
ACUTE MI ARE SILENT

• DIAGNOSIS IS BY ECG AND CARDIAC MARKERS

• IMMEDIATE TREATMENT INCLUDES OXYGEN, ANTIANGINAL DRUGS, ANTIPLATELETE, ANTICOAGULANTS
• FOR NSTEMI PATIENTS WHO ARE STABLE, DO ANGIOGRAPHY WITH PERCUTANEOUS CORONARY INTERVENTION
(PCI); IF IMMEDIATE PCI IS NOT AVAILABLE, GIVE FIBRINOLYTICS.
• FOLLOWING RECOVERY, INITIATE OR CONTINUE ANTIPLATELET DRUGS, BETA BLOCKERS, ACE INHIBITORS &
STATINS.