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Yusra Pintaningrum
Dept. of Cardiology & Vascular Medicine
Epidemiology
MI occurs every 2 mins in UK Account for 100,000 deaths annually Cardiovascular death accounts for 40% all deaths under the age 75 yrs Major cause of cardiac arrest
Mechanisms of ischaemia
Ischaemia disturbance in myocardial oxygen supply and demand Impaired coronary artery blood flow
Atherosclerosis Coronary artery spasm Dissection Tachycardia shortened diastole
Right side
Jaw
Epigastrium
Back
Atherosclerosis
Pathology of atherosclerosis
Lipid laden macrophages form fatty streak
Progressive stenosis
Anatomy
1. Aorta
2. Right Coronary Artery 3. Left Anterior Descending Artery 4. Circumflex Coronary Artery
Risk Factors
Fixed
Age
Modifiable
Smoking
Male sex
Menopause Family history
Hypertension
Hyperlipidaemia Obesity
Diabetes
Alcohol
Sedentary lifestyle
Stable angina
Myocardial ischaemia without muscle necrosis Caused by
Fixed stenosis Coronary artery spasm Other disease hypoxia, valvular disease
History
Exercise related, pressing precordial chest pain, can radiate to jaw and left arm, often relieved by nitrates. Can also manifest as breathlessness
Stable angina
Investigations
ECG
Often normal or non specific changes such as T wave inversion, can show ST depression reflecting ischaemia
Exercise ECG
ECG changes related to exertion particularly ST depression, dysrhythmias, hypotension
Symptom control
Nitrates dilate coronary arteries
Rest
Beta blockers
Antagonists of adrenaline & noradrenaline Reduced contractility and heart rate
Calcium antagonist
Vasodilation (especially dihydropyidines) Prolongation of action potential, antidysrrythmic
Severe IHD
Stable angina uncontrolled by medication
Right side
Jaw
Epigastrium
Back
PATHOPHYSIOLOGY
Goals of Treatment
Reduce Infarct size Reduce Mortality Prevention of Unfavorable Clinical Events
Recurrent Myocardial infarction Congestive heart failure Sudden death Avoid complication
Safety
Arrhythmias
Repeat Intervention
Satler L. SCAI-ACC I2 Summit 2008
MANAGEMENT STEMI
ED
CCU
Cath Lab
EMS on-scene
Encourage 12-lead ECGs Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min
Goals
Patient 5 min after symptom onset EMS on Dispatch scene 1 min
EMS transport
EMS transport:EMS-to-Balloon within 90 min
Within Prehospital fibrinolysis : Patient self-transport:Hospital Door-to-Balloon within 90 min 8 min EMS-to-Handle within 30 min
Investigations
ECG - initially hyperacute T waves, then ST elevation, then T wave inversion then Q waves Chest x-ray Bloods FBC, U&Es, LFTs, Glucose, Cardiac enzymes
? Echo
CCU monitored bed
Reperfusion Therapy
Percutaneous Coronary Intervention
Used for STEMI as these suggest full thickness infarction Should be done in <90mins
Method: Occluded vessel identified, guidewire passed, balloon inserted, stent inserted
Advantages
Culprit artery re-opened to normal calibre
Lower risk of major bleeding
Reperfusion Therapy
Thrombolysis
Advantages easy to perform, can be done quickly
Disadvantages
Inability to achieve reperfusion in all cases
Risk of inducing bleeding Cannot detect success of reperfusion
Contraindications
Recent CVA or previous haemorrhagic stroke Recent surgery
Active bleeding
Secondary prevention
Low Molecular Weight Heparin 1mg/kg OD Aspirin Clopidogrel Beta blocker usually Bisoprolol ACE inhibitor Glycoprotein IIb/IIIa inhibitor Statin Cardiac rehabilitation
CABG
Usually reserved for severe triple vessel disease not amenable to PCI Two forms
Vein grafts leg saphenous veins, quick to apply, annual failure 8% Arterial grafts more technically difficult, better long term survival, uses internal mammary artery
1% mortality if elective Prior to surgery optimise diabetes, do pulmonary function tests and vein mapping
Complications
Sudden death P- pump failure R- rupture of papillary muscle or septum E- embolism A- aneurysm and arrhythmias
D- Dresslers syndrome
Immediate - Dysrhythmias
Ventricular tachycardia/fibrillation usually respond well to resuscitation Sinus tachycardia heart failure or anxiety Sinus bradycardia early change particularly with inferior infarcts can treat with atropine Atrial fibrillation poor prognosis as indicates myocardial damage Complete heart block
Inferior MI usually resolves alone
Anterior MI bad prognosis, may need pacemaker
Heart failure
Left ventricular dysfunction can lead to hypotension, pulmonary oedema and renal impairment Treatment diuretics, nitrates, ACE inhibitor, later a beta blocker Cardiogenic shock very poor prognosis
Other complications
Pericarditis 48hrs after full thickness MI, widespread ST elevation Septal rupture acute haemodynamic deterioration, pansystolic murmur, treatment is surgery (2-5 days) Ruptured papillary muscle causes mitral prolapse (hours days) Left ventricular aneurysm persistent ST elevation Mural thrombus secondary to poor LV contraction Dresslers syndrome self limiting autoimmune pericarditis 2-3 weeks post MI
Post MI counselling
Explain medications and their use 2 months off work and avoid heavy labour Avoid sex for one month
THANK YOU