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Download Acute management of myocardial infarction
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Transcript
MYOCARDIAL INFARCTION CASE 1 • Mr. A: 38 years old • He smokes 1 pack of cigarettes per day • He has no other past medical history • 8 hours ago, he gets sharp central chest pain that is worse with inspiration. It has not yet resolved. • He feels short of breath CASE 2 • Mr. D: 50 years old • He also smokes 1 pack of cigarettes per day • His past medical history includes hypertension and diabetes • While he was working on the farm, he develops dull central chest pain that radiates to his neck • With rest, the pain went away after about 5 minutes • He also has shortness of breath WHICH PATIENT IS HAVING AN MI? WH Y ? HISTORY • Pain • Location • Exertional • Other symptoms: • Shortness of breath • Nausea • Sweaty • Risk Factors • • • • • • Family history Diabetes Hypertension Smoking Hyperlipidemia Previous MI or stroke PHYSICAL EXAM • Vital signs • BP • HR • O2 saturation • Cardiac exam • S3 or S4 may be present • Murmur of mitral regurgitation • May have heart failure on cardiac and respiratory exam ECG: ST ELEVATION MI ECG ECG: NON ST ELEVATION MI ECG STEMI VERSUS NSTEMI MANAGEMENT: CASE When you examine Mr. D, he can talk to you • BP 110/70 HR 100 O2 93% on room air • He has normal heart sounds, no murmur, but has S4 • Lungs are clear • ECG shows ST depression and T wave inversion in V2- V6. • What do you want to do next? MANAGEMENT • First, ABC’s! • If you have cardiac monitor, put him on it • IV access • Oxygen • What medications do you want to give him? • For his pain? • To prevent further thrombosis (antithrombotics)? • To prevent arrythmia? • To treat other cardiac risk factors? MEDICATIONS: PAIN • Nitrates • Vasodilation of coronary arteries • Decrease preload (venous vasodilation) • Decrease afterload (arterial vasodilation) • Be careful of hypotension (aortic stenosis, right ventricular MI) • Morphine • Avoid NSAIDS if you can MEDICATIONS: ANTITHROMBOTIC • Aspirin • 162-325mg Po chewed x 1 then 75mg-100mg daily • Patient needs to take indefinitely • Decreases mortality • Give as soon as you suspect an MI • Consider clopidogrel • 300mg PO x 1 then 75mg daily for 1-12 months • Small additional benefit MEDICATIONS: ANTICOAGULANTS • Heparin • Decreases risk of death and re-infarction • If using unfractionated heparin IV, monitor PTT • Duration is at least 48 hours MEDICATIONS: PREVENTING ARRYTHMIA • Beta blockers (eg. Atenolol, propranolol, metoprolol) • Decreases mortality and ventricular arrythmias • Start within 24 hours • Contraindications • Acute heart failure • Heart block • Asthma • Hypotension • No role for antiarrythmics such as lidocaine or digoxin • No role for calcium channel blockers MEDICATIONS • ACE inhibitors (ramipril, enalopril) • Especially beneficial in those with heart failure • Start within 24 hours • Prevents left ventricular remodelling REPERFUSION • 2 options • A) Fibrinolytics • If symptoms started less than 24 hours ago • Contraindications: Uncontrolled hypertension, stroke in last 3 months, previous intracranial hemorrhage • For STEMI patients only • B) Percutaneous coronary intervention (PCI) • If symptoms started less than 12 hours ago • If the “door to balloon” time can be less than 90 minutes • For STEMI patients. Can consider for NSTEMI patients REPERFUSION • Which NSTEMI patients should you think about sending for reperfusion? • Chest pain and ischemia not responding to medications • Unstable patients • Arrythmias • Heart failure COMPLICATIONS • Heart failure • Bradycardia from AV (conduction) block • Arrythmia • Non sustained ventricular tachycardia (VT) • Sustained VT and ventricular fibrillation • New mitral regurgitation • Ventricular wall rupture • Cardiogenic shock