Myocardial infarction

MI

1. MYOCARDIAL INFARCTION Mr. Melvin Jacob MSc (N) 1 Mr. Melvin Jacob

2. Definition An MI occurs when there is a diminished blood supply to the heart which leads to myocardial cell damage and ischemia. Otherwise know as heart attack Contractile function stops in the necrotic areas of the heart. Ischemia usually occurs due to blockage of the coronary vessels . 2 Mr. Melvin Jacob

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5. MI classifications MI’s can be categorized by clinical diagnostic information. Non ST elevations (STEMI) ST elevations (NSTEMI). 5 Mr. Melvin Jacob

6. Non ST elevation MI It is an acute ischemic event causing necrosis. ST segment depression and T wave inversion may present in the ECG 6 Mr. Melvin Jacob

7. ST elevation MI It is the most serious form of ACS. Electrocardiogram shows significant ST segment elevation depends on the affected area 7 Mr. Melvin Jacob

8. The leads represent different region of the heart 8 Mr. Melvin Jacob

9. Anterior wall MI ST segment elevation in the anterior leads (V3 and V4)  Reciprocal ST segment depression in the inferior leads (II, III and aVF) 9 Mr. Melvin Jacob

10. Inferior wall MI ST segment elevation in the inferior leads (II, III and aVF) Reciprocal ST segment depression in the lateral and/or high lateral leads (I, aVL, V5 and V6) 10 Mr. Melvin Jacob

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12. Posterior wall MI ST depression in V2-3 Tall, broad R waves (> 30ms) in V2-3 Dominant R wave in V2 Upright terminal portions of the T waves in V2-3 12 Mr. Melvin Jacob

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14. Lateral wall MI ST elevation in the lateral leads (1, aVL, V 5 &V 6 ) Reciprocal depression in inferior leads III & aVF 14 Mr. Melvin Jacob

15. Septal wall MI Septal MI is associated with ST elevation, Q wave formation and T wave inversion in the leads overlying the septal region of the heart (V2 and V3) 15 Mr. Melvin Jacob

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18. Ethiology Atherosclerotic plaque rupture with superimposed thrombus/95%/ Coronary embolism (e.g., from endocarditis, artificial heart valves) Congenital anomalies of the coronary arteries Coronary trauma or aneurysm 18 Mr. Melvin Jacob

19. Severe coronary artery spasm (primary or cocaine-induced) Increased blood viscosity (e.g., polycythemia vera , thrombocytosis ) Spontaneous coronary artery dissection Markedly increased myocardial oxygen demand (e.g., severe aortic stenosis) 19 Mr. Melvin Jacob

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22. Smoking Tobacco use increases the risk of coronary artery disease two to six times more than non smokers. Nicotine increases platelet thrombus adhesion and vessel inflammation. 22 Mr. Melvin Jacob

23. Diabetes & Hypertension Diabetes not only increases the rate of atherosclerotic formation in vascular vessels but also at an earlier age. The constant stress of high blood pressure has been associated with the increased rate of plaque formation. Shearing Stress and inflammation of endothelial lining begins the process. 23 Mr. Melvin Jacob

24. Hyperlipidemia Elevated levels of cholesterol, LDL’s or triglycerides are associated with the increased risk of coronary plaque formation and MI. 24 Mr. Melvin Jacob

25. Obesity and Physical Inactivity Mortality rate from CAD is higher in those who are obese. Some evidence shows that those who carry their weight in their abdomen have a higher incidence of CAD Physically inactive people have lower HDL levels with higher LDL levels and an increase in clot formation. 25 Mr. Melvin Jacob

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28. Signs and Symptom s Signs and symptoms are unique to each individual patient. Ranging from no symptoms to sudden cardiac arrest. 28 Mr. Melvin Jacob

29. Chest Pain The most common initial manifestation is chest pain or discomfort. This is not relieved by rest, position change or nitrate administration. Pain is described by heaviness, pressure, fullness and crushing sensation. Not everyone experiences this sensation. 29 Mr. Melvin Jacob

30. PQRST assessment for chest pain P- Precipitating events Q- Quality of pain R- Radiation of pain S- Severity of pain T- Timing 30 Mr. Melvin Jacob

31. Pain indicators Description Location Behind side of sternum, left side of chest Radiation Left arm, jaw, neck Characterizes Pressure, dull, squeezing, aching, crushing, burning /elephant sitting in the chest Duration >10-20mins Relieving factor No abatement of nitroglycerin , relieved with analgesic/morphine 31 Mr. Melvin Jacob

32. Nausea and Vomiting Not everyone will experience this. Vomiting results as a reflex from severe pain. Vaso-vagal reflexes initiated from area of ischemia. 32 Mr. Melvin Jacob

33. Cardiovascular Changes Initially the BP and pulse may be elevated. Later, BP will drop due to decreased cardiac output. Urine output will decrease Lung sounds will change to crackles Jugular veins may become distended and have obvious pulsations. 33 Mr. Melvin Jacob

34. In women most common symptoms include shortness of breath, weakness and fatigue. Loss of consciousness & cardiogenic shock 34 Mr. Melvin Jacob

35. Diagnostic evaluation History collection Physical examination ECG Blood investigations Echocardiogram Cardiac catheterization 35 Mr. Melvin Jacob

36. ECG 12 lead EKG’s can help to distinguish between ST-elevation MI’s and Non-ST elevation MI’s STEMI ST segment elevations T wave changes Q wave development Enzyme elevations Reciprocals 36 Mr. Melvin Jacob

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38. NSTEMI ST segment depressions T wave changes No Q wave development Mild enzyme elevations No reciprocals 38 Mr. Melvin Jacob

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40. STEMI vs. NSTEMI 40 Mr. Melvin Jacob

41. Serum cardiac markers Myocardial cells produce certain proteins and enzymes associated with cellular functions. When cell death occurs, these cellular enzymes are released into the blood stream. CPK and troponin 41 Mr. Melvin Jacob

42. Creatine Phosphokinase It is an enzyme specific to the cells of the brain, myocardium & skeletal muscles Primary function of CPK is energy production CPK release to the blood when irreversible injury occur to the cells CPK normal value is 15- 105 u/l for men & 10- 80 u/l for women 42 Mr. Melvin Jacob

43. Troponin Troponin found in the cardiac & skeletal muscles. Myocardial muscle protein released into circulation after injury. Appearance in blood indicate necrosis to the myocardium These are highly specific indicators of MI. Troponin rises quickly like CK but will continue to stay elevated for 2 weeks. Normal value is 0.0- 0.4 ng /ml 43 Mr. Melvin Jacob

44. Time course for serum markers in acute MI Markers Time of initial elevation Time of peak elevation Time to return to normal CPK 4-8 h 12-24 h 72-96 h Troponin I 4-6 h 12 h 3- 10 days 44 Mr. Melvin Jacob

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46. Echocardiography Echocardiography is a non-invasive diagnostic technique which provides information regarding cardiac function and hemodynamics Evaluation of ventricular function Presence of regional wall abnormalities Aortic dissection and pericardial effusion. 46 Mr. Melvin Jacob

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49. Chest x-ray 49 Mr. Melvin Jacob

50. Cardiac catheterization Cardiac catheterization (cardiac cath or heart cath) is a procedure to examine how well your heart is working. A thin, hollow tube called a catheter is inserted into a large blood vessel that leads to your heart.  50 Mr. Melvin Jacob

51. Check the pressure in the four chambers of your heart. Take samples of blood to measure the oxygen content in the four chambers of your heart. Evaluate the ability of the pumping chambers to contract. Look for defects in the valves or chambers of your heart. Remove a small piece of heart tissue to examine under a microscope (biopsy). 51 Mr. Melvin Jacob

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55. Management 55 Mr. Melvin Jacob

56. Morphine Analgesic Sedative Reducing fear Dilate venous reduce heart burden 4-8 mg by IV Repeat 2-4 mg by IV in 5-15 mins Highest dose is 20mg 56 Mr. Melvin Jacob

57. Oxygen 2-8 liter per minute by nasotubule or mask Saturation: >90% 57 Mr. Melvin Jacob

58. Nitroglycerin Dilating coronary artery 0.3-0.6 mg by sublingual or spray Repeat 2 times in 5 minute Infusion 5 mcg/kg/bodyweight 58 Mr. Melvin Jacob

59. Aspirin 150-325 mg by chew followed by 75 mg bd Antiplatelet agent Clopidogrel 150mg stat & 75mg OD 59 Mr. Melvin Jacob

60. Thrombolytic therapy Anistreplase Streptokinase Urokinase Tenectplase Streptokinase: 1.5 lakh IU diluted in 100ml normal saline and administered with in one hour 60 Mr. Melvin Jacob

61. Tenecteplase Pt Wt Mg Infusion rate <60 30 mg 6 ml/hr ≥60 to <70 35 mg 7 ml/hr ≥70 to <80 40 mg 8 ml/hr ≥80 to <90 45 mg 9 ml/hr ≥90 50 mg 10 ml/hr 61 Mr. Melvin Jacob

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63. Beta blockers Decrease the blood pressure & rate Helps to relax the heart muscles Dosage is 5mg IV for q2minute for 3 dose followed by 50mg p/o q6H for 48 hours then 100mg Bd 63 Mr. Melvin Jacob

64. ACE inhibitor Lower the blood pressure & reduce the stress on the heart Dosage: 2.5- 5mg bd orally can increase up to 20 mg in 2 divided dose 64 Mr. Melvin Jacob

65. Calcium channel blockers Interrupt the movement of calcium in the cells of the heart Dosage: 5-10 mg once daily 65 Mr. Melvin Jacob

66. Diuretics Helps to remove excess fluid and sodium in the body through increasing the urine Dosage: 20-80 mg orally in single or divided dose can increase up to 600mg 66 Mr. Melvin Jacob

67. Interventional procedures Angioplasty It is a minimallyinvasive ,  endovascular procedure to widen narrowed or obstructed arteries or veins, typically to treat arterial atherosclerosis. A deflated balloon attached to a catheter (a balloon catheter) is passed over a guide-wire into the narrowed vessel and then inflated to a fixed size 67 Mr. Melvin Jacob

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70. Atherectomy Atherectomy  is a minimally invasive endovascular surgery technique for removing atherosclerosis from blood vessels within the body. Unlike angioplasty and stents, which push plaque into the vessel wall, atherectomy cuts plaque from the wall of the artery 70 Mr. Melvin Jacob

71. Cardiomyoplasty Cardiomyoplasty  is a surgical procedure in which healthy muscle from another part of the body is wrapped around the heart to provide support for the failing heart. Most often the  latissimus dorsi muscle is used for this purpose. A special pacemaker is implanted to make the skeletal muscle contract 71 Mr. Melvin Jacob

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73. Radiofrequency ablation  ( RFA ) Radiofrequency ablation (RFA) is a medical procedure in which part of the electrical conduction system of the heart,  tumor  or other dysfunctional tissue is ablated using the heat generated from medium frequency alternating current (in the range of 350–500 kHz) 73 Mr. Melvin Jacob

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75. Trans myocardial revascularization Laser drilled small holes from ventricles in to myocardium allowing blood to flow directly in to the heart muscles without the need to travel through blocked coronary arteries 75 Mr. Melvin Jacob

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77. Coronary artery bypass graft Coronary artery bypass grafting (CABG) is a type of surgery that improves blood flow to the heart. It's used for people who have severe coronary heart disease. 77 Mr. Melvin Jacob

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81. THANK YOU 81 Mr. Melvin Jacob