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1. Complications Of
ACS
Arrhthymias
•Common
•Usuallytransient
•Needs no action apart fromclose
observation Unless they are causing
1haemodynamic compromise ie Hypotension
2Or carry a bad prognostic implication suchlate
onset Ventricular Tachycardia (VT)

2. Arrhythmias in ACS VT and
VF
•Ventricular Fibrillation(VF)
Can occurs spontaneously
orcomplicates VentricularTachycardia ( VT)
•The major mode of death before hospitalization
•Early VF has no bad prognosis
•Treatment ;- Defibrillatepromptly
Ventriculat TachycardiaVT
1Slow VT isfrequent good sign of reperfusion;
called Idioventricular rhythm. It is self limiting. No
RX
2Other VT must Defibrillate promptly3if not giveIV Amiodarone5 mg
/kg followed by 15mg/kg 24hrs
infusion
4Beta blockers can prevent VT
20 min.- 2hrs bolus

3. VF ; Ventricular
Fibrilation

4. Ventricular
Tachycardia

5. Atrial
Fibrillation AF
1common
2frequently transient
3require no emergency treatment
4Rapid AF with Haemodynamic compromise
require urgent synchronized DC shock
5AF due to stretch of atrial wallis often a feature
of impending or overtLV failure
and therapy are ineffective unless HF is treated
appropriately eg IV diuretics
6Otherwise Digoxin0. 25 m TIDthen
0.25 daily after or a betablocker

6. Fast
AF

7. ?? Af and complete Heat
Block

8. ACScomplications;
Arrhythmia
1- Sinus BradycaridiaandAtrio- ventricular block
(2
nd degreeor complete AV Block)occur more
frequently in ptswith Inf. MI and both of them
usually require no treatment unless ;They haveled to
haemodynamic deterioration then ;
a- SinusBradycardia ;- IV atropine 0.6- 1.2 mg
b-Complete AV block require temporary Pacemaker
3-A temporary Pacemaker is certainly indicated for
complete heart block complicating Anterior MI
because asystole may suddenly supervene

9. First degree heart
block

10. 2-1
Block

11. Complete
AVblock

12. ACS complications Pericarditis:
Two types t
A- Early pericarditis
1occuron the 2
nd -3
rddays after STEMI
2Different pain ; little sharp, may be worse on lying down
and inspiration
3-+ Rub.
4-Use opiates. NoNonsteroidalAntiflamatory agents .
B.Late: Dressler’ s syndrome
•In few weeks.- months
•Autoimmune.
•Fever, pericarditis and pleurisy.
•Aspirin, NSAID,…Steroid

13. Post infarction
Angina
1Occur in 50% of pts following thrombolysis due to residual
stenosis
2Pts must be on full scale RX ; nitroglycerine infusion ,
Betablockers . Heparin, aspirin and referred for urgent
Angiography in the view of revascularization by PCI
3Pts with dynamic ECG changes should receive IV GP
11b
/11a receptors antagonist
4Pts wih resistant pain or those who are haemodynamically
unstablewould needs Intraa-ortic Balloon
counterpulsation

14. Cardiogenic
Shock
Caused by
1 -L.V dysfunction in 70 % of cases
2- RV MI
3- Mechanical complications due to rupture
of part of myocardiumincluding
a- RupturedIVS … Acquired VSD
b Ruptured papillary muscle Acute MR
c- Ruptured free wall pericard. tamponade

15. Acute MI Haemodynamic
subsets
•Pts with Cadiogenic shock can be dividedintointo
Four distinct groups depending
upon their haemodynamic criteria they are
G1 Normal CO and no P. Oedema……No Rx
G2 Low CO and no P. Oedema. It isusually due to RV MI.
Treatment :- Give IV fluids.Use Swanz Ganz catheter
to monitor therapy. Consider PCI
G3 Normal CO and P Oedema .It is due moderate
LV dysfunction Treatment:-Vasodilators and
diuretics
G4 Low CO and P. Oedema due to extensive MI and poor
prognosis ..Consider IAB, vasodilators, diuretics and
inotrops and refer for PCI

16. Mechanical
complications…..
Rupture of the papillary
muscle
•
Sudden onset of Pulmonary Oedema
and shock in pt who
has apical pansystolic
murmur and a third heart sound
•Very severe MRreduces the
murmur intensity and increases the
shock
•DX by Echo.
•Rx isurgent surgery
•Minor degree of MR is due to Papillary
muscle dysfunction and can be transient

17. Rupture of the interventricular
septum Acquired VSD
•Sudden haemdynamic deterioration
•New loudLt.- sternal pansystolic
murmur radiating to the Rt. sternal
border
•Rt. sided heart failure rather than
pul oedema
•Hence JVP is raised and the lungs
are usually dry
•Without urgent operation it is
usually fatal

18. Free wall
Rupture•Leads to sudden tamponade
•Usually fatal
•But in partial rupture it may be possible
to support pt to undergo urgent surgery

19. LV
aneurysm
Occur in Transmural MI
Occur in 105 of Pts
More in pts with
persistent IRA
occlusion
Fibrosis leads to stretching, thinning,expansion of the infarct
zone
Increased wall stress leads to progressive dilatation and
hypertrophy of remaining muscle
LV dilationleads to reduction of vent. Efficiency
Heart Failure, vent arrhythmia, mural thrombi
ECG Persistent ST elevation
CXRBulge. Echo is Diagnostic, Rx surgical
Resection

22. Anterolateral
MI