Acute coronary syndrome. Diagnosis, treatment and prophylaxis of myocardial infarction

Acute myocardial infarction

1. Acute coronary syndrome.
Diagnosis, treatment and
prophylaxis of myocardial
infarction.
Dr Manoj Godara
MBBS

2. Worldwide Statistics
Each year:
•> 4 million patients are admitted with
unstable angina and acute MI
•> 900,000 patients undergo PTCA
with or without stent

3. Acute Coronary Syndrome
Ischemic Discomfort
Unstable Symptoms
No ST-segment
elevation
ST-segment
elevation
Unstable Non-Q Q-Wave
angina AMI AMI
ECG
Acute
Reperfusion
History
Physical Exam

4. Acute Coronary Syndrome
•The spectrum of clinical conditions
ranging from:
–unstable angina
–non-Q wave MI
–Q-wave MI
•characterized by the common
pathophysiology of a disrupted
atheroslerotic plaque

9. Definition:
•Myocardial infarction
(MI)or acute myocardial
infarction (AMI),
commonly known as a
heart attack, is the
result of interrupted
blood supply to a part of
the heart, causing heart
cells to die.

10. Etyology:

11. Risk factors for atherosclerosis
are generally risk factors for
myocardial infarction
•Diabetes(with or without insulin
resistance) –the single most important
risk factor for ischaemic heart disease
(IHD)
•Tobacco smoking
•Air pollution
•Hypercholesterolemia (more accurately
hyperlipoproteinemia, especially high low
density lipoprotein and low high density
lipoprotein)

12. Risk factors for atherosclerosis
•Low HDL
•High Triglycerides
•High blood pressure
•Family history of ischaemic heart
disease (IHD)
•Obesity

13. Risk factors for atherosclerosis
•Age
•Hyperhomocysteinemia (high
homocysteine, a toxic blood amino acid
that is elevated when intakes of vitamins
B2, B6, B12 and folic acid are insufficient)
•Stress —Occupations with high stress
index are known to have susceptibility for
atherosclerosis
•Alcohol —Studies show that prolonged
exposure to high quantities of alcohol can
increase the risk of heart attack
•Males are more at risk than females.

14. The characteristics of an acute MI
depend on the following factors:
1) location, severity, rate of coronary atherosclerotic
obstruction
2) size of area perfused by occluded coronary
blood vessels
3) duration of occlusion
4) myocardial needs of affected area
5) degree of development of collateral blood vessels
6) site and severity of vasospasm (if present)
7) changes in BP, HR, heart rhythm

15. Symptoms:
•Patients with acute MI often complain of severe
retrosternal painlasting more than 30 minutes
and not relieved by sublingual nitroglycerin;
•Nausea, diaphoresis, and vomitingare also
common.
•It is important to note that clinical presentation
and intensity of symptoms vary widely among
individuals. This is especially true in women, the
elderly, and diabetics who may present with
atypical or only mild symptoms that go
unrecognized. Sometimes there is no pain
present, and patients may present with a
complication of acute MI (see below) such as
pulmonary edema.

16. Signs:
•Increased HR and BP (but
bradycardia is also not uncommon
as a presentation). S3 or S4 sounds.
New murmurs due to papillary
muscle ischemia and/or rupture.

17. Investigations of Acute MI
ECG:An ECG should be obtained as soon
as possible. Look for Q waves in the
tracings although they need not be
present in acute MI. Also look for ST
segment elevation or depression and T
wave inversion. It is important to keep in
mind that 10% of patients presenting with
acute MI will have normal ECG tracings
therefore it would be prudent to repeat the
ECG later.

18. Investigations of Acute MI
•Cardiac Enzyme Studies:CK-MB is
the most sensitive and specific
marker of MI. The blood levels of CK-
MB rise by 6-8 hrs and peak at 12-48
hrs later. LDH levels are useful if the
patient presents days after a
suspected MI.

19. Investigations of Acute MI

20. Investigations of Acute MI

21. ECG:

22. ECG:

23. ECG:

24. ECG:

25. Coronarography

26. Treatment of Acute MI
•supplemental oxygen
•-continuous ECG monitoring
•-aspirin 160-325 mg PO
•-morphine 2-4 mg IV q 5-15 min. if needed
•-thrombolytic therapy if patient presents
within 6 hrs of MI onset: tPA,
streptokinase
•-direct PTCA
•-bed rest for 24-36 hrs and admission to
CCU

27. Acute coronary syndrome without
ST elevation
•The main aim of the outpatient phase
a diagnosis and immediate
transportation to the profile hospital.

29. The basic diagnostic
measurement.
Laboratory tests:
•Highly sensitive troponin I at admission and
again after 1-3 hours, or 0-1 hours after the
presence of the corresponding analyzers, (all
in quantitative methods measurement).
•CBC(hemoglobin, hematocrit, platelets, etc.).
•CUT
•serum creatinine, glomerular filtration rate
•The lipid profile (cholesterol, LDL, HDL,
triglycerides)
•Blood Glucose
•Potassium

30. Risk stratification of patients with based
on the presence of clinical risk factors
and quantitative risk assessment on the
scale of GRACE
The criteria of very high risk
•Hemodynamic instability or cardiogenic shock
•Recurrent or continuing chest pain, resistant to
medical treatment
•life-threatening arrhythmias or cardiac arrest
•The mechanical complications of MI
•Acute heart failure with refractory angina or ST-
segment deviation
•Repeated dynamic changes in ST segment or T
wave

31. Risk stratification of patients with based
on the presence of clinical risk factors
and quantitative risk assessment on the
scale of GRACE
The criteria for high risk
•Elevation or lowering of cardiac
troponins associated with MI•
Dynamic changes of the ST segment
or T wave (symptomatic or
asymptomatic)
•The amount of points on the scale of
GRACE> 140

32. Criteria for intermediate risk
•Diabetes
• Renal insufficiency (GFR <60 mL / min / 1.73
m2)• LVEF <40%, or congestive heart failure
• The early post-infarction angina pectoris
• The recent conduct of PCI• The preceding
coronary artery bypass graft
• The amount of scores on the risk scale of
GRACE> 109 and <140

33. Criteria of low-risk
•Any characteristics not mentioned
above
•Electronic calculatorofGRACEscale:
http://www.outcomes.org/grace

34. Complications of Acute MI
1. cardiogenic shock when 40+% of LV
infarcted
2. cardiac perforation -external or
interventricular
3. embolism
4. CHF
5. papillary muscle rupture
6. rhythm disturbances
7. pericarditis -autoimmune (Dressler’s
syndrome)

37. The list of Essential Medicines:
•1. Oxygen inhalation (medicinal gas)
•2. Metoprolol tartrate (1% vials 5,0ml; 50 mg
tablet)
•3. Nitroglycerin * (0.1% solution for injection in
vials of 10 ml; 0.0005 g tablet or spray).
•4. Morphine (injection ampoule in 1 ml of 1.0%)
•5. Aspirin (tablet, 500 mg)
•6. Ticagrelor (tablet 90 mg)
•7. clopidogrel (tablet, 75 mg)
•8. Fondaparinux (0.5 ml syringe 2.5 mg)
•9. enoxaparin sodium (0.2 and 0.4 syringe ml)
•10. Physiological saline (0.9% 200 ml bottle)

38. Algorhythm

39. Thank you!