Sumary about Heart Attack

1. ACUTE CORONARY SYNDROME
MYOCARDIAL INFARCTION
Heart Attack
Jagranzotti

2. Myocardial Infarction
 Chest pain >30min felt like “gas”or pressure
 That may produce ,arrhythmias, heart failure ,
hypotension and shock
 Rarely painless
 Eletrocardiography with ST elevation or
depression, inverted “T” wave evolving to “q”
waves
 Elevation of cardiac enzymes CK-MK , Troponin
T >0,01mcg/l

3. Myocardial Infarction- Reperfusion
 PCI percutaneus Coronary Intervention and
fibrinolysis
 PTCA:- percutaneus transluminal coronary
angioplasty
 Stenting : Pharmacologic and no pharmacologic
(BMS)
 CABG Coronary artery bypass grafting

4. MI - Causes
 Atherosclerosis
 Hypotension
 Aortic or coronary dissection,
 Anomalous of Left Coronary Artery (alcapa)
 Embolic Occlusion
 Aortitis
 Systemic hypertension
 Post –prandial exercices

5. Diagnosis
 Anterior chest pain, irradiated for left shoulder,
epygastrium and back patient is anxious and sweting
profuse;low cardiac output; btadycardia or
tachycardia. Hypertension or hypotension when in
shock
 Eletrocardiogram (EKG) Nstemi and Stemi
 CK-MB e Troponin T and I  high levels
 Hypotension and arrhythmias Heart failure or
Shock
 Scintigraphic studies with Technetium –m99
pyrophosphate or scintigraphy with Thallium 201 to
perfusion evaluation, that may show “cold spots”

6. CARDIAC IMAGING
 Echo 2 D – Abnormalities of wall motion (akinesis
,diskinesis)
 LV function (ejection fraction)
 Doppler Echocardiography.. Quantification of
mitral regurgitation and ventricular septal defect
 RMI Coronary calcification quantification

7. MI –Myocardial Infarction
ECG
 MI without supra- elevation of of segment ST(
NSTEMI) Sub- occlusion of coronary artery Non
Q Wave Infarction or unstable angina
 Myocardial Infarction with supra elevation of
segment ST- Total occlusion of coronary artery
(STEMI) Q Wave infarction
Location :-
Anterior, Antero-lateral, Posterior and inferior
infarction could be transmural (Q Wave ) and sub-endocardial(
Non Q Wave)

8. Killip Classification
 Killip class I  signs of heart failure
 Killip class II  Rales and diffuse weezing in the
lungs
 Killip Class III  acute pulmonary edema
 Killip Class IV  Cardiogenic Shock

9. Myocardial Infarction --TIMI Risk
 TIMI Risk Thrombolysis in Myocardial Infarction
 Variables: Age over 75; diabetes;Killip Class;
Heart rate > 100 bpm; Systolic blood pressure
below 100 mmHg;

10. Initial Management
 Transfer to Coronary Intensive Care Unit (CICU)
Time is Muscle!
 Continuous monitoring of Cardiac Rhythm by
Telemetry
 Cardioversion if necessary
 Inotropics and anti-arrhythmics drugs
 Mechanical Ventilation
 Pos-op of Open Heart Surgery
 IABP: Intra-aortic Balloon Pump for cardiogenic
shock

11. Initial management
STEMI patients
 1-Fibrinolysis : tPA ,(tissue plasminogen activator)
alteplase or actilyse
 2- PTCA (percutaneous transluminal coronary
angiography )
Coronary Angioplasty or Stenting Implantation (BMS)
bare metal stents no Pharmacologic Stents or
Pharmacologic Stents with rapamicina or everolimus
Special cases: Open heart surgery for revascularization
Nstemi patients :-Options Stenting or Surgery:
Revascularization when appropriate, multivessel.Isn’t
indicated fibrinolysis

12. General Measures
 EKG telemetry, monitoring Cardiac Arrhythmias
 Analgesia—morphine or meperdine
 Beta-Adrenergic blocking agents
 Nitrates
 Angiotensin- Converting Enzyme inhibitors (ACEi)
 Prophilaxis for arrhythmias ( Ventricular
Fibrillation ) with Lidocaine
 Calcium Channel Blockers
 Anticoagulation : UFH- Heparin and Abciximab

13. Complications
 Ischemias
 Arrhythmias  Atrioventricular Block,
Supraventricular tachyarrhythmias ,ventricular
premature beats(extrasystoles), conduction
disturbances, atrial fibrillation
 Myocardial Dysfunction
 Ventricular aneurysm

14. Postinfarction management
 Risk Stratificatiom : Postinfarction angina; Non Q
Wave MI; Low LV ejection fraction <40%
 Ventricular ectopy > 10 extrasystoles/h Ischemia
Induced by stress.
 Revascularization: Positive evidence of multivessel
disease, by exercices tests and low ejection fraction
<40% in non Q wave infarction, they are candidates to
revascularization Options : (PCI) Percutaneus
Coronary Intervention or (CABG) Coronary Artery
Bypass Grafting
 Less evidence for patients with ejection fraction >
50% and no evidence of ischemia in exercices tests