Download acute coronary syndrome

ST ELEVATION MYOCARDIAL INFARCTION
YEDITEPE UNIVERSITY FACULTY OF MEDICINE
PHASE 4 CARDIOLOGY COURSE 2014-2015
PROF. MUZAFFER DEGERTEKIN, M.D., PhD.
MUSTAFA AYTEK SIMSEK, M.D., Attending
Physician
Coronary Disease Progression
Acute Coronary Syndrome
CORONARY
THROMBOSIS WITH
INFARCTION
CORONARY ATHEROSCLEROSIS WITH
THROMBOSIS -(MI)
No Q wave - Q wave
Why spared?
ELECTROCARDIOGRAPHY



10 minutes after
presentation
New persistent or transient
ST-segment abnormalities
(≥0.1 mV) and T inversion
(≥0.2 mV)
During a symptomatic
episode at rest and resolve
ECG
ASSESSMENT OF REPERFUSION OPTIONS
FOR STEMI PATIENTS
Step 1: Assess time and risk.

Time since onset of symptoms

Risk of STEMI

Risk of fibrinolysis

Time required for transport to a skilled PCI
laboratory
A
C
B
D
AN INVASIVE STRATEGY IS GENERALLY
PREFERRED IF


Skilled PCI laboratory is available with surgical
backup

Skilled PCI laboratory is available, defined by

Medical contact-to-balloon or door-to-balloon less
than 90 min
High risk from STEMI

Cardiogenic shock

Killip class ≥ 3

Contraindications to fibrinolysis,

Late presentation

Symptom onset was more than 3 hr ago
HEMODYNAMIC CLASSIFICATIONS OF
PATIENTS WITH ACUTE MYOCARDIAL
INFARCTION

Based on Clinical Examination
I.
Rales and S3 absent
II.
Crackles, S3 gallop, elevated jugular venous
pressure
III.
Frank pulmonary edema
IV.
Shock
Modified from Killip T, Kimball J: Treatment of myocardial infarction in a
coronary care unit. A two year experience with 250 patients. Am J Cardiol
20:457, 1967
HEMODYNAMIC CLASSIFICATIONS
OF PATIENTS WITH ACUTE
MYOCARDIAL INFARCTION

Based on Invasive Monitoring
I.
Normal hemodynamics; PCWP < 18 mm Hg, CI > 2.2
II.
Pulmonary congestion; PCWP > 18 mm Hg, CI > 2.2
III.
Peripheral hypoperfusion; PCWP < 18 mm Hg, CI < 2.2
IV.
Pulmonary congestion and peripheral hypoperfusion;
PCWP > 18 mm Hg, CI < 2.2
Modified from Forrester J, Diamond G, Chatterjee K, et al: Medical therapy of
acute myocardial infarction by the application of hemodynamic subsets. N Engl J
Med 295:1356, 1976.
GENERAL TREATMENT MEASURES

Antiplatelet Therapy

Anticoagulant Therapy

Control of Cardiac Pain


Analgesics

Nitrates

Beta Blockers

Oxygen
Limitation of Infarct Size

Early reperfusion

Reduction of myocardial energy demand
ANTIPLATELET THERAPY

Aspirin

162-325 mg, nonenteric-coated ASA to be chew

maintenance of 75-162 mg daily
ANTIPLATELET THERAPY



Clopidogrel 300-600 mg
loading 75 mg/day
Prasugrel oral loading dose
of 60 mg and 10 mg orally
daily
Ticagrelor a loading dose
of 180 mg and 90 mg
twice daily
ANTICOAGULANT THERAPY



Heparin activated partial
thromboplastin time
(aPTT) target of 1.5 to 2
times that of control
Low-Molecular-Weight
Heparins
Bivalirudin (STMI)
FIBRINOLYSIS IS GENERALLY PREFERRED IF
 Delay


to invasive strategy:

Prolonged transport

Medical contact-to-balloon or door-to-balloon more
than 90 min
Early presentation (≤3 hr from symptom onset and
delay to invasive strategy; see below)
Invasive strategy is not an option:

Catheterization laboratory occupied or not available

Vascular access difficulties

Lack of access to a skilled PCI laboratory
APPROVED FIBRINOLYTIC AGENTS
CONTROL OF CARDIAC PAIN

Analgesics



meperidine, pentazocine, and morphine
Morphine 2 to 8 mg/ 5 to 15 minutes --until the pain is
relieved or there is evident toxicity
Nitrates

sublingual nitrates, intravenous nitroglycerin

systolic pressure <90 mm Hg

right ventricular infarction
CONTROL OF CARDIAC PAIN

Beta Blockers

Killip class II or higher (precipitating cardiogenic shock)

Patients with heart failure (rales > 10 cm up from diaphragm),

hypotension (blood pressure < 90 mm Hg),

bradycardia (heart rate < 60 beats/min),
CONTROL OF CARDIAC PAIN

Oxygen

pulse oximetry

Sao2 < 90%

2 to 4 liters/min of 100% oxygen

6 to 12 hours
LIMITATION OF INFARCT SIZE

Early reperfusion

Routine Measures for Infarct Size Limitation



Beta blocker (HR 50-70)
Inhibitors of the renin-angiotensin-aldosterone
system (RAAS)
Arterial oxygenation
LIMITATION OF INFARCT SIZE

Angiotensin-converting enzyme (ACE) inhibitor



Start ACE inhibitor orally in patients with pulmonary
congestion or LVEF <40%
if the following are absent: hypotension (SBP <100 mm Hg
or <30 mm Hg below baseline) or known contraindications
to this class of medications.
Angiotensin receptor blocker (ARB)

Start ARB orally in patients who are intolerant of ACE
inhibitors and with either clinical or radiologic signs of
heart failure or LVEF <40%
COMPLICATIONS OF MI
Myocardial Infarction
Ventricular
thrombus
Contractility
Embolism
Cardiogenic
shock
Ischemia
Electrical
instability
Arrhythmias
Tissue
necrosis
Pericardial
inflammation
Pericarditis
Hypotension
Coronary
perfusion
pressure
Papillary Ventricular Ventricular
muscle
septal
rupture
infarction/ defect
ischemia
Mitral
regurgitation
Congestive
heart failure
Cardiac
tamponade
RECURRENT ISCHEMIA
• Angina or ischemia confers
increase risk for reinfarction
• Should lead to angiography
and revascularization for most
pts.
ARRHYTHMIAS IN ACUTE MI
Rhythm
Cause

Sinus Bradycardia
- Vagal tone
- SA nodal artery perfusion

Sinus Tachycardia
- CHF
- Volume depletion
- Pericarditis
- Chronotrophic drugs (e.g.
Dopamine)


APB’s, atrial fib,
VPB’s, VT, VF
- CHF
AV block (1o, 2o, 3o)
- IMI: Vagal tone and AV nodal
artery flow
- AMI: Extensive destruction of
conduction tissue
- Atrial Ischemia
- Ventricular ischemia
- CHF
BLOOD SUPPLY IN THE
CONDUCTION SYSTEM
Conduction Pathway
SA node
 AV node
 Bundle of His
 RBB
LAD

Primary Arterial Supply
- RCA (70% of patients)
- RCA (85% of patients)
- LAD (septal branches)
- Proximal portion by
- Distal portion by RCA

LBB
Left anterior fascicle
Left posterior fascicle
- LAD
- LAD and PDA
MYOCARDIAL DYSFUNCTION
 Congestive
Heart Failure
 Systolic or diastolic
 Treated with vasodilators, diuretics, and Rx
to reverse ischemia
 Cardiogenic Shock
 Depressed CO
 Hypotension
 Poor perfusion of vital organs
 Treatment: Look/Treat reversible cause
 Inotropes/vasodilators/IABP
CARDIOGENIC SHOCK - MI - 1Y
1.0
Proportion Alive
0.8
Early Revascularization - n=152
0.6
0.4
Initial Medical Stabilization - n=150
0.2
0
0
2
4
6
8
Time From Randomization, mo
Benefit < 75 Years
10
12
Shock (JS Hochman et al.) JAMA 2001; 285:190
RV INFARCTION
Common
in IMI’s
Sx/signs:

Hypotension

Increase RA Pressure
Rx:

Volume, hemodynamic monitoring…PA line
PAPILLARY MUSCLE INFARCTION
 “Common”
 Leads
in inferoposterior MI
to acute mitral valve
regurgitation
 Left
 Rx:
heart failure/pulmonary edema
Coronary revascularization;
IABP; valve repair
FREE WALL RUPTURE
 More
likely in elderly, HTN, women
 Usually
rapidly fatal
 Occasional
walls off to form
pseudoaneurysm
 Urgent
surgery is best chance
VENTRICULAR SEPTAL DEFECT
 Heralded
by left to right shunting at
ventricular level
 RV
volume overload
 Loud
systolic murmur over sternum
 Usually
requires surgical repair
TRUE VENTRICULAR ANEURYSM
Occurs
More
late
often in non-reperfused
STEMI’s
Complications:
arrhythmias
Clot, CHF,
PERICARDITIS

More common in non-reperfused STE MI

Fever, sharp pain with pleuritic tendency, friction rub

Treatment: nonsteroidal anti-inflammatory agent;
heparin relatively contraindicated
THROMBOEMBOLISM
Clot
forms on infarcted akinetic
myocardium
Most
Can
Rx:
If
common in large anterior MI
cause embolic stroke
3-6 months anticoagulants
clot seen on echo or LVEF < 30% or
if large anterior MI
LONG
TERM
MANAGEMENT

Lifestyle modificiations

Medical Treatment

Invasive Procedures

Prevention
AFTER STEMI
LIFESTYLE MODIFICIATIONS
 Diet & salt restriction
Weight reduction
Smoking
Physical activity
Avoid precipitating factors (walking into
a wind or uphill, cold weather, large
meals)
MEDICAL TREATMENT

Aspirin

ACE inhibitors

Beta-blockers

Calcium channel blockers

Nitrates

Statins
LONG TERM THERAPIES

Risk factor control, particularly smoking, must be stringent.

Antiplatelet therapy is indicated indefinitely.

Dual antiplatelet therapy is indicated up to 12 months.

Oral treatment with beta-blockers is indicated in patients
with heart failure or left ventricular dysfunction.

A fasting lipid profile must be obtained in all patients.

A high-dose statin should be initiated or continued early
after admission in all patients without contraindication or
history of intolerance.

ACE inhibitors are indicated in patients with heart failure,
LV systolic dysfunction diabetes or an anterior infarct.

An ARB is an alternative to ACE inhibitors.

Aldosterone antagonists are indicated if EF ≤40% or heart
failure or diabetes, provided there is no renal failure or
hyperkalaemia.