Presentation on

myocardial infarction

By- Dr.Vinay Vatsayan

Presenting Symptoms of Acute
MI
 Pain-
*typical-crushing substernal chest pain
*atypical - jaw, neck, shoulder, back pain, indigestion
*painless - “silent”
 Dyspnea-
systolic and/or diastolic dysfunction
 Dizziness-hypotension, arrhythmia
 Nausea, vomiting
 Elderly patients: Failure to thrive
 Anxiety, restlessness, “sense of impending doom”
Presenting Signs in Acute MI
 Appearance: Pallor, diaphoretic, anxious
 Vital Signs: Normal or abnormal BP and P
– Hypertension and tachycardia: SNS
– Hypotension and tachycardia:
 Cardiogenic shock

 Myocardial rupture

 Tachyarrhythmia

– Hypotension and bradycardia

 vagal stimulation

 Bradyarhythmia
 Presenting Signs in Acute MI
(Cont.)
 Lungs: Rales - CHF
 Heart: Displaced LV impulse
– S3
– S4
– Murmur of mitral regurgitation
– Murmur of ventricular septal
rupture
– Pericardial rub
Evolution of ECG changes in acute MI
Cardiac enzymes
Natural History of Acute
Myocardial Infarction
 Death-
– Arrhythmia: VT/VF
– Asystole
– Myocardial rupture
– Cardiogenic shock
 Chronic Heart Disease -
– LV dysfunction - remodeling
– Papillary muscle dysfunction: MR
– RV dysfunction
 Natural History of Acute
Myocardial Infarction, (Cont.)
 Stabilization compensated LV
dysfunction
 Post-infarction angina/ischemia
(spontaneous or induced)
 Recurrent MI
 Post-infarction ventricular tachycardia
Treatment of Acute
Myocardial Infarction: Acute
Phase
 Prevent/resuscitate from sudden death:
monitor, admit to CCU

 Re-establish coronary flow

– Thrombolytic therapy
– Primary infarct angioplasty/stent
 Major Contraindications To the Use of
Thrombolytic Therapy
 Any previous history of hemorrhagic stroke
 History of stroke, dementia, or central nervous system
damage within 1 year
 Head trauma or brain surgery within 6 months
 Known intracranial neoplasm
 Suspected aortic dissection
 Internal bleeding within 6 weeks
 Active bleeding or known bleeding disorder
 Major surgery, trauma, or bleeding within 6 weeks
 Traumatic cardiopulmonary resuscitation within 3 weeks
Treatment of acute MI:
acute
phase (cont.)
 Decrease myocardial oxygen demand
– Pain relief/anxiolytics (Morphine sulfate)
– Slow HR, control BP (beta blockers)
 Increase myocardial oxygen supply
– Oxygen
– Prevent platelet aggregation/coronary thrombus
(aspirin, IIbIIIa inhibitors, clopidigrel/heparin)
– Prevent spasm (nitrates)
– Augment collateral flow (nitrates)
Treatment of Acute Myocardial
Infarction: Acute Phase (Cont.)

 Stabilize plaques, restore endothelial function

– ? HMG CoA reductase inhibitors (“statins”)
 Prevent ventricular remodeling
– ACE inhibitors
 Prevent mural thrombus/embolization
– Heparin
– Coumadin for patients at high risk for thrombus
(anterior wall akinesis).
Treatment of Acute
Myocardial Infarction -
Intermediate Phase
 Monitor/treat arrhythmias
 Monitor/treat heart failure: systolic,
diastolic, MR
 Monitor/treat recurrent ischemia/infarction
 Watch for pericarditis, Dressler’s Syndrome
 Monitor for myocardial rupture (free wall,
VSD, MR)
 Monitor for stroke
Determinants or Prognosis
after Acute MI
 LV function (ejection fraction)
 Inducible ischemia/coronary anatomy
 Arrhythmia potential
Treatment of acute myocardial
infarction: Pre-discharge
 Risk assessment
– Is there LV systolic dysfunction?
– Is there inducible ischemia?
– Is there “high risk” coronary anatomy?
– Is there VT/VF risk?
Tests for LV function

 Echocardiogram
 Radionuclide ventriculogram
(MUGA)
 Contrast left ventriculogram (cath)
Echocardiogram in Acute
Myocardial Infarction
 Wall motion abnormalities
 Ejection fraction
 Thrombus
 Right ventricular MI
 Papillary muscle dysfunction- mitral
regurgitation
 Free wall rupture/ventricular septal
defect/papillary muscle rupture
 Test for Inducible ischemia:
Stress Test
 1. Positive: Ischemic ST segment
depression - 1mm horizontal or
downsloping ST depression
 2. Negative: Patient reaches 85%
maximum predicted heart rate (MPHR)
without #1
 3. Nondiagnostic: No ischemia but patient
fails to reach 85% MPHR
 Test to Define Coronary
Anatomy: Coronary
Angiogram
 Controversy: Should all patients
undergo coronary angiogram after an
MI?
– Definite indications for coronary angiogram
after MI:
 Recurrent chest pain
 Positive stress test
 High risk features: CHF, low EF, prior MI
Risks of Coronary
Angiography: (all are rare)
 Stroke
 Myocardial infarction
 Arrhythmia
 Renal failure
 Allergic reaction to contrast agent
Tests to Determine Arrhythmia
Risk:
 Monitoring throughout hospitalization
 Stress test
 Electrophysiologic testing
– Controversy: Who should undergo EP
study after MI?
– Sustained VT
– Nonsustained VT with depressed ejection fraction
Treatment of Acute Myocardial Infarction
Late Phase (Post-Hospital)
 Risk factor reduction:
– Smoking
– Hypertension
– Diabetes
– Dyslipidemia
– Obesity/sedentary life style
– Hyperhomocysteinemia
– Stress/depression
 Monitor for recurrent ischemia
 Monitor for LV remodeling/CHF
ABCs of Treatment and
Secondary Prevention of AMI
 Aspirin-prophylactic Rx for recurrent ischemic events; give
for at least 3 mo. after AMI, probably indefinitely
 Beta blockers-prophylactic, for reduction of cardiac
mortality; Rx for 2 yr-indefinitely
 Converting enzyme inhibitors-all pts with LV dysfunction
to reduce risk of progressive heart failure and death.
 Diet and lipid lowering Rx-statins have been shown to
reduce risk of subsequent MI, need for revascularization and
mortality (4S, Care)
 Exercise and rehabilitation-essential in restoration of
confidence and improvement in quality of life
Creatine Phosphokinase (CK)
 Rises within 4-8 hours, rapidly cleared by 24-24 hours
 Other Sources:
– Skeletal
– Hypothyroidism
– Renal failure
– Stroke
 Isoenzymes
– MM skeletal muscle
– BB brain
– MB cardiac
 CKMB 4% suggests acute myocardial infarction+++
Cardiac Specific Troponins
(cTnT, cTnI)

 Rise within 4-8 hours, remain elevated

7-14 days (T>I)
 30% of patients with UAP show 
levels cTnT or I, indicating increased
risk of adverse outcome
 Relative Contraindications To the Use of
Thrombolytic Therapy

 Oral anticoagulant therapy

 Acute pancreatitis
 Pregnancy or within 1 week postpartum
 Active peptic ulceration
 Transient ischemic attack within 6 months
 Dementia
 Infective endocarditis
 Active cavitating pulmonary tuberculosis
 Advanced liver disease
 Intracardiac thrombi
 Uncontrolled hypertension (systolic blood Pressure >180 mm Hg, diastolic blood pressure >
110 mm Hg
 Puncture of noncompressible blood vessel within 2 weeks
 Previous streptokinase therapy