Mi
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إعداد و تقدي طلب سنة سادسة معاذ عيّاد – يزيد جبيل -سهر العلي
Objectives New Universal Definition of MI and Its Types. Epidemiology, Pathophysiology and Risk
Factors. Clinical features, Investigations and Diagnosis. Management. Prevention. Complications Prognosis.
Introduction The Universal Definition of Acute Myocardial Infarction states that
the term Myocardial Infarction should be used when there is evidence of myocardial necrosis in a clinical setting consistent with myocardial ischemia. Classification of Myocardial Infarction: o Type 1: Spontaneous Myocardial Infarction related to ischemia due to primary coronary event such as plaque erosion or rupture, fissuring or dissection. o Type 2: Myocardial Infarction due to secondary ischemia due to imbalance between oxygen demand and supply. eg, coronary spasm, anemia, and hypotension. o Type 3: Sudden cardiac death with symptoms of ischemia, accompanied by ST elevation or LBBB, or verified coronary thrombus by angiography or autopsy, but death occurring before blood samples could be obtained. o Type 4 a: Myocardial Infarction associated with PCI. o Type 4 b: Myocardial Infarction associated with verified stent thrombosis. o
Epidemiology
21.2 %
1 6. 3 5 0. 2. 2 % 4. 7 4 % 3 % % %
Epidemiology
1. 7 %
38 1. .5 23 7 % .1 30 % 4. % .8 3 % %
Pathophysiology
Causes and Precipitating Factors Fixed 2.Age 3.Male sex 4.Positive family history
Potentially
changeable: 2. Hyperlipidaemia 3. Cigarette smoking 4. Hypertension
5. Diabetes mellitus 5.Deletion polymorphism in the
ACE gene (DD)
6. Obesity 7. Lack of exercise 8. Blood coagulation factors 9. Homocysteinaemia 10.Gout 11.Contraceptive pill
Clinical presentation History: o Chest pain (discomfort) described as substernal central squeezing, aching, burning, or even sharp pain. o Shortness of breath o Atypical presentations 20%. o Family H’x. o Risk factors in Past, social and personl H’x. o Other associated symptoms.
Clinical presentation. cont Physical examination o Low-grade fever o Hypotension or hypertension o Fourth heart sound (S4) o Dyskinetic cardiac bulge o Systolic murmur o Signs of congestive heart failure (CHF ). o Other findings include cool, clammy skin and diaphoresis.
Differentials Pulmonary embolism Aortic dissection, aortic stenosis. Spontaneous pneumothorax Acute Pericarditis or Myocarditis. Reflux oesophagitis, oesophageal spasm. Acute gastritis or Cholecystitis. Anxiety disorders and others.
Investigations The electrocardiogram (ECG) is the most important tool in the initial evaluation , it confirms diagnosis of .80% Cardiac Biomarkers : Troponin levels & Creatine kinase. level
Investigations.cont .Myoglobin levels .Complete blood cell count .Chemistry profile .Lipid level profile C-reactive protein (CRP) .levels
Chest radiography Echocardiography Myocardial perfusion imaging Cardiac angiography
o o o o
ECGexample
ECGexample
Management
Prehospital Phase:
All patients being transported for chest pain should be managed as if the pain were ischemic UNTIL PROVED OTHERWISE. Treatment of patients with suspected STEMI with morphine, oxygen, nitroglycerin, and aspirin (AHA recommended). Specific prehospital care includes the following: o o o o
IV access, supplemental oxygen, pulse oximetry. Immediate administration of aspirin en route. Nitroglycerin for active chest pain, given sublingually or by spray. Telemetry and prehospital ECG, if available.
Management cont. Hospital Phase: 2. The evaluation of patients with chest pain begins with a 12-
lead ECG even as the physician is beginning a focused history, including contraindications to fibrinolysis, and a targeted physical examination. 3. Patients with confirmed no ST-segment elevation are not candidates for immediate thrombolytics but should receive anti-ischemic therapy. 4. Treatment is aimed at: o
Restoration of the balance between the oxygen supply and demand to prevent further ischemia.
Management cont. The decision as to whether the patient will be
treated with thrombolysis or recanalization (CABG or primary PCI) should be made within 20 minutes upon arrival. All patients should be monitored, two large-bore IVs, pulse oximetry and oxygen should be given. A chest radiograph should be obtained.
Management cont. Pharmacologic intervention: Aspirin should be administered immediately (162 to 325 mg). Use clopidogrel in case of aspirin allergy. IV heparin: 1. 2.
Initial bolus 60 IU/kg, maximum, 4000 IU. Then 12 IU/kg/hour, maximum 1000 IU/hour, adjusted to maintain aPTT=1.5 to 2 times the control value) or LMWH (enoxaparin) 30 mg intravenous bolus, then 1 mg/kg SC b.i.d.
Patients with chest pain should be given sublingual
nitroglycerin (0.4 mg every 5 minutes for a total of three
Management cont. Pharmacologic intervention: Persistent ischemic pain may be treated with titrated to IV doses of morphine (2 to 4 mg repeated every 5 to 15 minutes). Initiation of ß-blocker therapy (The best is Metoprolol 5 mg IV every 5 min 3 times; titrate to heart rate and SBP) is usually indicated, especially in patients with hypertension, tachycardia, and ongoing pain; however, decompensated heart failure is a contraindication to the acute initiation of ß-blocker therapy, particularly by the intravenous route.
Management cont. Pharmacologic intervention: An ACE inhibitor (Captopril 6.25 mg PO tid) should be given within the first 24 hours to patients with anterior MI, pulmonary congestion, or LVEF<40% in the absence of hypotension. If intolerant, an angiotensin receptor blocker (valsartan or candesartan) should be administered. The ideal systolic blood pressure is 100 to 140 mm Hg. Excessive hypertension responds to titrated nitroglycerin, ß-blocker therapy, and morphine. Relative hypotension could require discontinuation of
Complications Complications: ARRHYTHMIAS: Sinus bradycardia, Supraventricular tachyarrhythmias,
Ventricular arrhythmias, Conduction disturbances. MYOCARDIAL DYSFUNCTION: Acute left ventricular failure, Hypotension and shock. RIGHT VENTRICULAR INFARCTION. MECHANICAL DEFECTS: Partial or complete rupture of a papillary muscle or of the interventricular septum occurs in less than 1% of acute myocardial infarctions and carries a poor prognosis. MYOCARDIAL RUPTURE. LEFT VENTRICULAR ANEURYSM. PERICARDITIS. MURAL THROMBUS.
Prevention Cigarette smoking
Hypertension: achieve a goal of less than 140/90 mm Hg. Diabetes mellitus: goal of normal fasting plasma glucose
(<125 mg/dl). Hyperlipidemia: HDL <40 mg/dl, family history of premature coronary heart disease, or age (>45 years for men, >55 years for women)], the LDL goal for primary prevention is less than 160 mg/dl. If multiple risk factors are present, the LDL goal is less than 130 mg/dl. Obesity: body mass index of less than 25 kg/m 2. Physical activity for at least 30 minutes/day
Prognosis
Acute MI is associated with a 30% mortality rate;
half of the deaths occur prior to arrival at the hospital. An additional 5-10% of survivors die within the first year after their MI. Approximately half of all patients with an MI are rehospitalized within 1 year of their index event. Overall, prognosis is highly variable and depends largely on the extent of the infarct, the residual LV function, and whether the patient underwent
References Cecil Medicine, 23rd Ed Harrison's Principles of Internal Medicine, 17th
Edition, 2008 eMedicine.com Specialties > Endocrinology > Diabetes Mellitus
Thank You Any Questions ?
Objectives New Universal Definition of MI and Its Types. Epidemiology, Pathophysiology and Risk
Factors. Clinical features, Investigations and Diagnosis. Management. Prevention. Complications Prognosis.
Introduction The Universal Definition of Acute Myocardial Infarction states that
the term Myocardial Infarction should be used when there is evidence of myocardial necrosis in a clinical setting consistent with myocardial ischemia. Classification of Myocardial Infarction: o Type 1: Spontaneous Myocardial Infarction related to ischemia due to primary coronary event such as plaque erosion or rupture, fissuring or dissection. o Type 2: Myocardial Infarction due to secondary ischemia due to imbalance between oxygen demand and supply. eg, coronary spasm, anemia, and hypotension. o Type 3: Sudden cardiac death with symptoms of ischemia, accompanied by ST elevation or LBBB, or verified coronary thrombus by angiography or autopsy, but death occurring before blood samples could be obtained. o Type 4 a: Myocardial Infarction associated with PCI. o Type 4 b: Myocardial Infarction associated with verified stent thrombosis. o
Epidemiology
21.2 %
1 6. 3 5 0. 2. 2 % 4. 7 4 % 3 % % %
Epidemiology
1. 7 %
38 1. .5 23 7 % .1 30 % 4. % .8 3 % %
Pathophysiology
Causes and Precipitating Factors Fixed 2.Age 3.Male sex 4.Positive family history
Potentially
changeable: 2. Hyperlipidaemia 3. Cigarette smoking 4. Hypertension
5. Diabetes mellitus 5.Deletion polymorphism in the
ACE gene (DD)
6. Obesity 7. Lack of exercise 8. Blood coagulation factors 9. Homocysteinaemia 10.Gout 11.Contraceptive pill
Clinical presentation History: o Chest pain (discomfort) described as substernal central squeezing, aching, burning, or even sharp pain. o Shortness of breath o Atypical presentations 20%. o Family H’x. o Risk factors in Past, social and personl H’x. o Other associated symptoms.
Clinical presentation. cont Physical examination o Low-grade fever o Hypotension or hypertension o Fourth heart sound (S4) o Dyskinetic cardiac bulge o Systolic murmur o Signs of congestive heart failure (CHF ). o Other findings include cool, clammy skin and diaphoresis.
Differentials Pulmonary embolism Aortic dissection, aortic stenosis. Spontaneous pneumothorax Acute Pericarditis or Myocarditis. Reflux oesophagitis, oesophageal spasm. Acute gastritis or Cholecystitis. Anxiety disorders and others.
Investigations The electrocardiogram (ECG) is the most important tool in the initial evaluation , it confirms diagnosis of .80% Cardiac Biomarkers : Troponin levels & Creatine kinase. level
Investigations.cont .Myoglobin levels .Complete blood cell count .Chemistry profile .Lipid level profile C-reactive protein (CRP) .levels
Chest radiography Echocardiography Myocardial perfusion imaging Cardiac angiography
o o o o
ECGexample
ECGexample
Management
Prehospital Phase:
All patients being transported for chest pain should be managed as if the pain were ischemic UNTIL PROVED OTHERWISE. Treatment of patients with suspected STEMI with morphine, oxygen, nitroglycerin, and aspirin (AHA recommended). Specific prehospital care includes the following: o o o o
IV access, supplemental oxygen, pulse oximetry. Immediate administration of aspirin en route. Nitroglycerin for active chest pain, given sublingually or by spray. Telemetry and prehospital ECG, if available.
Management cont. Hospital Phase: 2. The evaluation of patients with chest pain begins with a 12-
lead ECG even as the physician is beginning a focused history, including contraindications to fibrinolysis, and a targeted physical examination. 3. Patients with confirmed no ST-segment elevation are not candidates for immediate thrombolytics but should receive anti-ischemic therapy. 4. Treatment is aimed at: o
Restoration of the balance between the oxygen supply and demand to prevent further ischemia.
Management cont. The decision as to whether the patient will be
treated with thrombolysis or recanalization (CABG or primary PCI) should be made within 20 minutes upon arrival. All patients should be monitored, two large-bore IVs, pulse oximetry and oxygen should be given. A chest radiograph should be obtained.
Management cont. Pharmacologic intervention: Aspirin should be administered immediately (162 to 325 mg). Use clopidogrel in case of aspirin allergy. IV heparin: 1. 2.
Initial bolus 60 IU/kg, maximum, 4000 IU. Then 12 IU/kg/hour, maximum 1000 IU/hour, adjusted to maintain aPTT=1.5 to 2 times the control value) or LMWH (enoxaparin) 30 mg intravenous bolus, then 1 mg/kg SC b.i.d.
Patients with chest pain should be given sublingual
nitroglycerin (0.4 mg every 5 minutes for a total of three
Management cont. Pharmacologic intervention: Persistent ischemic pain may be treated with titrated to IV doses of morphine (2 to 4 mg repeated every 5 to 15 minutes). Initiation of ß-blocker therapy (The best is Metoprolol 5 mg IV every 5 min 3 times; titrate to heart rate and SBP) is usually indicated, especially in patients with hypertension, tachycardia, and ongoing pain; however, decompensated heart failure is a contraindication to the acute initiation of ß-blocker therapy, particularly by the intravenous route.
Management cont. Pharmacologic intervention: An ACE inhibitor (Captopril 6.25 mg PO tid) should be given within the first 24 hours to patients with anterior MI, pulmonary congestion, or LVEF<40% in the absence of hypotension. If intolerant, an angiotensin receptor blocker (valsartan or candesartan) should be administered. The ideal systolic blood pressure is 100 to 140 mm Hg. Excessive hypertension responds to titrated nitroglycerin, ß-blocker therapy, and morphine. Relative hypotension could require discontinuation of
Complications Complications: ARRHYTHMIAS: Sinus bradycardia, Supraventricular tachyarrhythmias,
Ventricular arrhythmias, Conduction disturbances. MYOCARDIAL DYSFUNCTION: Acute left ventricular failure, Hypotension and shock. RIGHT VENTRICULAR INFARCTION. MECHANICAL DEFECTS: Partial or complete rupture of a papillary muscle or of the interventricular septum occurs in less than 1% of acute myocardial infarctions and carries a poor prognosis. MYOCARDIAL RUPTURE. LEFT VENTRICULAR ANEURYSM. PERICARDITIS. MURAL THROMBUS.
Prevention Cigarette smoking
Hypertension: achieve a goal of less than 140/90 mm Hg. Diabetes mellitus: goal of normal fasting plasma glucose
(<125 mg/dl). Hyperlipidemia: HDL <40 mg/dl, family history of premature coronary heart disease, or age (>45 years for men, >55 years for women)], the LDL goal for primary prevention is less than 160 mg/dl. If multiple risk factors are present, the LDL goal is less than 130 mg/dl. Obesity: body mass index of less than 25 kg/m 2. Physical activity for at least 30 minutes/day
Prognosis
Acute MI is associated with a 30% mortality rate;
half of the deaths occur prior to arrival at the hospital. An additional 5-10% of survivors die within the first year after their MI. Approximately half of all patients with an MI are rehospitalized within 1 year of their index event. Overall, prognosis is highly variable and depends largely on the extent of the infarct, the residual LV function, and whether the patient underwent
References Cecil Medicine, 23rd Ed Harrison's Principles of Internal Medicine, 17th
Edition, 2008 eMedicine.com Specialties > Endocrinology > Diabetes Mellitus
Thank You Any Questions ?
