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Myocardial infarction

Cardiac causes Myocardial ischaemia (angina), Myocardial


of chest pain infarction(MI),Myocarditis, Pericarditis, Mitral valve
prolapse (MVP), Aortic stenosis, Aortic dissection,
Aortic aneurysm
Non cardiac causes of chest pain
Emotional Anxiety, fear ,stress
Gastric causes GERD, Oesophagitis and spasm, Mallory-Weiss
syndrome
Pulmonary Pulmonary embolism, Pulmonary infarct, Pleuritis,
Pneumonia, Pneumothorax, Malignancy

Musculoskeletal Costochondritis (Tietze ‘s syndrome) , Rib fracture,


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

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