INFARCT MIOCARDIC ACUT

INFARCT MIOCARDIC ACUT

- este necroza unor miocite cardiace aparuta in urma unei
ischemii miocardice acute prelungite rezultata, de cele mai
multe ori prin tromboza intracoronariana
 INFARCT MIOCARDIC ACUT
CU SUPRADENIVELARE DE
SEGMENT ST

STEMI (ST elevation myocardial

infarction)
-Etapa prespital este cea mai importanta etapa in abordarea unui pacient cu
STEMI
- in primele 4-6 ore de la debut instabilitatea electrica a inimii este maxima,
riscul de aritmii maligne (in special fibrilatie ventriculara )este major
- in absenta contraindicatiilor toti pacientii cu STEMI trebuie tratati in
prespital cu anticoagulante (heparina nefractionata sau enoxaparina) si cu
dubla antiagregare

- ASPIRINA este obligatorie (per os sau parenteral)

-DUBLA ANTIAGREGARE: ASPIRINA +

1. TICAGRELOR 180 mg este prima optiune pentru pacientii care sunt

trimisi la angioplastie per primam (daca nu ticagrelor nu este
disponibil pacientul va primi clopidogrel 600 mg per os)

sau

2. CLOPIDOGREL 300 mg daca se practica FIBRINOLIZA (tromboliza)

From: 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment
elevationThe Task Force for the management of acute myocardial infarction in patients presenting with ST-segment
elevation of the European Society of Cardiology (ESC)
Eur Heart J. Published online August 26, 2017. doi:10.1093/eurheartj/ehx393
Eur Heart J | © The European Society of Cardiology 2017. All rights reserved. For permissions please email:
journals.permissions@oxfordjournals.org.
From: 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment
elevationThe Task Force for the management of acute myocardial infarction in patients presenting with ST-segment
elevation of the European Society of Cardiology (ESC)
Eur Heart J. Published online August 26, 2017. doi:10.1093/eurheartj/ehx393
Eur Heart J | © The European Society of Cardiology 2017. All rights reserved. For permissions please email:
journals.permissions@oxfordjournals.org.
From: 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment
elevationThe Task Force for the management of acute myocardial infarction in patients presenting with ST-segment
elevation of the European Society of Cardiology (ESC)
Eur Heart J. Published online August 26, 2017. doi:10.1093/eurheartj/ehx393
Eur Heart J | © The European Society of Cardiology 2017. All rights reserved. For permissions please email:
journals.permissions@oxfordjournals.org.
TERAPIA FIBRINOLITICA – in primele 12 ore de la debutul simptomelor

-streptokinaza
- alteplaza
- reteplaza
Contraindications to Fibrinolytic Therapy
 TRATAMENT
- dubla antiagregare

- heparine (fractionata/nefractionata)

- statina (atorvastatina 80/zi – rol important in stabilizarea placilor de

aterom)

- metoprolol la pacientii fara semne de insuficienta cardiaca

- nitrati (nitroglicerina)

- IEC (captopril) – la pacientii cu STEMI si diabet zaharat, insuficienta

cardiaca , fractie de ejectie scazuta daca TA> 120 mm Hg

- antagonisti ai receptorilor de mineralocorticoizi (spironolactona/eplerenon)

daca pacientii cu STEMI au insuficienta cardiaca

- oxigenoterapie daca Sa O2 < 90 %

- protectie gastrica la pacientii cu istoric de ulcer/gastrita/HDS
 DIAGNOSTIC DIFERENTIAL

 miocardite (istoric de febra, mialgii, viroze respiratorii recente)

 embolia pulmonara (D dimeri pozitivi, CT torace cu substanta de contrast

evidentiaza trombi in arterele pulmonare, ecografia cardiaca evidentiaza
suprasolicitarea cordului drept)

 disectia de aorta – durere toracica mult mai intensa, frecvent cu sincopa,

aorta dilatata, fald de disectie vizibil ecografic sau la CT cu substanta de
contrast
 COMPLICATII

INSUFICIENTA CARDIACA

- apare datorita disfunctiei acute de pompa prin afectarea unei mase mari
din ventriculul stang
- furosemid intravenos, nitroglicerina intravenos (nu daca TA <90 mm Hg)
- IEC (captopril) - (nu daca TA <90 mm Hg)
- morfina si IOT daca congestia pulmonara este severa

SOCUL CARDIOGEN - persistenta TA< 90 mm Hg cu semne clinice de

hipoperfuzie
- se administreaza inotropi (dopamina, dobutamina)
- se recomanda coronarografie si revascularizare miocardic de urgenta
 COMPLICATII

ARITMII CARDIACE SI TULBURARI DE CONDUCERE

- incidenta mortii subite in prespital prin tulburari maligne de ritm cardiac

ramane crescuta
- tahicardie ventriculara/fibrilatie ventriculara – 6-8 % (terapie de reperfuzie
de urgenta)
- fibrilatie atriala – aprox 21% dintre pacientii cu IMA (se admnistreaza beta
blocante/amiodarona, anticoagulare; daca pacientii devin instabili
hemodinamic se face cardioversie electrica de urgenta

- bradicardia severa sau blocuri atrioventriculare care nu se rezolva dupa

terapia de reperfuzie necesita cardiostimulare
 COMPLICATII

COMPLICATII MECANICE:
- ruptura de perete liber de VS (momentul interventiei cirurgicale
controversat)
- ruptura de muschi papilari cu regurgitare mitrala acuta severa (mai
frecvent este afectat muschiul papilar postero-medial)

PERICARDITA - precoce (in primele 1-2 sapt) sau tardiva

ANEVRISMUL DE VENTRICUL STANG - 5 % (apare de obicei in

infarctele mari)

TROMB APICAL DE VENTRICUL STANG – cel mai frecvent in infarctele

anterioare; necesita anticoagulare cel putin 6 luni cu control ecocardiografic