Rib injury, Intercostal muscle injury Neurological Prolapsed intervertebral disc, Herpes zoster, Thoracic outlet syndrome, intercostal neuralgia(especially in diabetic patients) Acute MI • Myocardial infarction (MI) is defined as a clinical (or pathologic) event caused by myocardial ischemia in which there is evidence of myocardial injury or necrosis • Acute coronary syndrome (ACS) — There are three types of ACS: ST elevation (formerly Q- wave) MI (STEMI), non-ST elevation (formerly non-Q wave) MI (NSTEMI), and unstable angina (UA). • The first two are characterized by a typical rise and/or fall in biomarkers of myocyte injury. Chest pain of MI Symptoms Prolonged cardiac chest pain(> 30 minutes) Chest, throat, arms, Epigastrium or back Anxiety, fear, sweating Fear of impending death Nausea and vomiting Breathlessness(LV failure) Collapse/syncope(LV failure, heart blocks) Physical signs Signs of sympathetic activation Pallor, sweating, tachycardia Signs of vagal activation Vomiting, bradycardia Signs of impaired myocardial function Hypotension, oliguria, cold peripheries, Narrow pulse pressure, Raised jugular venous pressure, Soft first heart sound,presence of Third heart sound(S3), Diffuse apical impulse, Lung Crepitations (Pulmonary oedema) Signs of tissue damage Fever, Signs of complications, e.g. mitral regurgitation, pericarditis ECG-ST-Segment Elevation Myocardial Infarction or STEMI • ST elevation MI (ST elevation or new left bundle branch block) • New ST segment elevation at the J point in two contiguous leads with the cut-points: >0.1 mV in all leads other than leads V2-V3. • For leads V2-V3, the following cut points apply: ≥0.2 mV in men ≥40 years, ≥0.25 mV in men <40 years, or ≥0.15 mV in women. • LBBB, is present in approximately 7 percent of patients with an acute MI ST elevation MI Non ST-Segment Elevation Myocardial Infarction or NSTEMI :
• Acute chest pain with No ST segment elevation
in ECG • But elevated cardiac enzymes Myocardial enzymes • CK-MB rises in 4–8 h and generally returns to normal by 48– 72 h • A ratio (relative index) of CKMB : Total CK activity > 2.5 suggests myocardial injury • Cardiac Troponin T and Troponin I - elevated • Both tests may become positive as early as 4–6 hours after the onset of a myocardial infarction. • Levels of Trop T and I may remain elevated for 7–10 days after MI and, therefore, are generally not useful for evaluating suspected early reinfarction (CK MB is the choice in reinfarction) Management of Acute MI • Take care ABC • Start supplemental oxygen to patients with an arterial saturation <90%, patients in respiratory distress, due to either heart failure, or those with other high-risk features for hypoxia. • Pain:Inj. Morphine 5 to 10 mg IV with antiemetic (Metoclopramide 10 mg) can be used for pain control Anti platelets • Aspirin 300 mg chewable or soluble stat (then 150mg/day) • Platelet P2Y12 receptor blockers: Clopidogrel, Prasugrel, Ticagrelor • Clopidogrel 300 mg stat (then75 mg/day) • Continue Aspirin 150 + Clopidogrel 75 /day (aspirin 150 mg should be continued indefinitely) • Prasugrel - is a platelet inhibitor ,used in patients with acute coronary syndrome who are to be managed with PCI (percutaneous coronary intervention ) Dose : 60 mg oral loading dose and then continue at 10 mg orally OD +Aspirin • Ticagrelor loading dose 180 mg is current choice used in patients with acute coronary syndrome who are to be managed with PCI(percutaneous coronary intervention ) • Both prasugrel and Ticagrelor are preferred to clopidogrel in PCI patients. Beta blockers • They reduce myocardial oxygen demand by reducing heart rate • Metoprolol 5 mg IV (Repeated to maximum 15 mg) • Then start tab 12.5 mg - 50 mg BD • Avoid in asthma, heart failure, hypotension, bradyarrhythmias • Beta blockers should not be used in the setting of acute cocaine intoxication with chest pain due to the possibility of exacerbation of coronary artery vasoconstriction. Statins • Early initiation (within 24 hours of presentation) of statin therapy : Atorvastatin 80 mg stat • Then - High-dose statin treatment is recommended in acute coronary event : atorvastatin ≥40 mg or rosuvastatin ≥20 mg per day. Interventions • Primary Percutaneous Coronary Intervention (PCI) - • In comparison to thrombolytic therapy, it is associated with a 50% reduction in death risk and recurrent infarction • Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours' duration (At A PCI-Capable Hospital) Thrombolysis • Thrombolysis should ideally be initiated <30 min of presentation (i.e., door-to-needle time <30 min). • IV Streptokinase 1.5 million units in 100 ml saline given as IV infusion for 1 hour • IV Alteplase (human tissue plasminogen activator or t-PA) • IV bolus 15 mg followed by 0.75 mg/Kg body weight, but not exceeding 50 mg, over 30 minutes and then 0.5 mg/Kg body weight, but not exceeding 35 mg over 60 minutes • Thrombolysis should be done within 12 hours (when it is anticipated that primary PCI cannot be performed within 120 minute), and particularly within 6 hours of onset of symptoms (patients treated within 1–3 h of the onset of symptoms generally benefit most.) Anticoagulants • To prevent re-infarction after thrombolysis • After completion of the thrombolytic infusion, anticoagulation with IV heparin [ Bolus 60–70 U/kg (maximum 5000 U) IV followed by infusion of 12–15 U/kg per h (initial maximum 1000 U/h) titrated to maintain an activated partial thromboplastin time [aPTT] of 50–75 seconds ] is continued for at least 24 hours after alteplase, reteplase, or tenecteplase. Follow up of MI patients • Life Style Modification • Stop smoking, reduction of alcohol intake,Regular graded exercise (brisk walking 30 minutes),Diet regulation for weight reduction and lipid lowering • Drugs • Aspirin 150 mg/day + Tab. Clopidogrel 75 mg/day / Ticagrelor (Clopidogrel + Aspirin combinations are available) • Ticagrelor :Loading dose (following ACS event): 180 mg PO (two 90 mg tablets),Maintenance dose (for first year following ACS event): 90 mg PO BID,Maintenance dose (after 1 year with history of MI): 60 mg PO BID • Beta-blocker(Metoprolol)- reduces the long term mortality by 25% and sudden cardiac death • ACE Inhibitors ( or ARB ) – They reduce ventricular remodeling and prevent the onset of cardiac failure ( e.g. Ramipril 2.5-20 mg daily, Lisinopril 5-10 mg daily, monitor renal function, serum potassium ) • Statins – Irrespective of cholesterol levels, all patients should receive statins. • Spironolactone can reduce the mortality rate of patients with advanced heart failure