A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to a part of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck or jaw

1. Treatment of Acute
Myocardial Infarction

2. INTRODUCTION
• Prompt recognition is the key
• Earliest reperfusion gives maximum benefit
• First 60 minutes is called golden period
• Primary PCI vs Thrombolysis has almost same result when done in 1st
hour

3. Higher the TIMI flow lesser the mortality
• Irrespective the strategy to open
the occluded artery, a good
blood flow at the level of
capillary is must to ensure better
survival outcome.

4. Universal 4th Definition to classify ACS ,2020

5. 4th UNIVERSAL DEFINITION MI
• Chest pain:
• Typical:(3/3)
• Atypical :<3
• ECG :
• Every 10 minutes till diagnosis
• Biomarker :Serial if initial
negative
• ECHO is supportive

6. UNIVERSAL 4TH DEFINITION of MI ,2020
• Type 1: Plaque rupture – Thrombus
formation – Lumen occlusion
• Type 2: There is no base line
atheromatous plaque but
imbalance between supply and
demand causes ischemia.
• coronary dissection
• vasospasm
• Embolism
• microvascular dysfunction
• Type 3 : MI resulting in death when
biomarker values are unavailable
• Type 4a: MI during
• Type 4b: Stent Thrombosis causing
MI
• Type 5: CABG graft occlusion
causing MI

7. WHEN TO SUSPECT ACUTE MI
• CHEST PAIN
• SOB
• SYNCOPE
• SUDDEN CARDIAC ARREST

8. ECG: Within 10 minutes After First Contact
• ST-elevation/new LBBB
• NSTEMI
• unstable angina
• ST-depression, T wave inversions, or transient ST-elevation
• Nondiagnostic :Follow with serial ECG

10. 12 LEAD ECG
STEMI
• ST segment elevations ≥1 mm
(0.1 mV) in two anatomically
contiguous leads or ≥2 mm (0.2
mV) in leads V2 and V3
• New LBBB
NSTEMI/USA
• ST segment depressions or deep
T wave inversions without Q
waves

11. TIMELINE OF ST/T CHANGES IN STEMI
J-point elevation and
concave ST
J-point elevation and
convex ST
ST/T merge with
upward single
convexity

12. STEMI
• New ST-segment elevation at the
J-point in two contiguous leads
with the cut-points: ≥0.1 mV in
all leads other than leads V2-V3
• V2-V3:
• ≥2 mm in men ≥40 years
• ≥2.5 mm in men <40 years
• ≥1.5 mm in women regardless of age

13. NSTEMI
• New horizontal or down sloping
ST-depression ≥0.5 mm in two
contiguous leads
• and/or T inversion >1 mm in two
contiguous leads with prominent
R wave or R/S ratio >1

14. Left bundle branch block
• ST-depression of at least 1 mm
in leads V1, V2, or V3 or in leads
II, III, or aVF, with elevation of at
least 1 mm in lead V5
• Extremely discordant ST
changes (changes in the
opposite direction of the major
QRS vector of >5 mm) were also
reported to be suggestive of MI

15. Nondiagnostic initial ECG
• Wait and watch

16. Old Myocardial Infarction
• in the absence of left bundle
branch block or left ventricular
hypertrophy
• Any Q wave in leads V2 to V3 ≥0.02
sec or QS complex in V2 and V3;
• Q wave ≥0.03 sec and ≥0.1 mV
deep or QS complex in leads I, II,
aVL, aVF; or V4 to V6 in any two
leads of a contiguous lead grouping
(I, aVL; V1 to V6; II, III, aVF)
• R wave ≥0.04 sec in V1 to V2 and
R/S ≥1 with a concordant positive T
wave in the absence of a
conduction defect.

17. Findings on the ECG depend upon
• Duration – Hyperacute, acute, evolving, or chronic
• Size – Amount of myocardium affected
• Location – Anterior, lateral, inferior-posterior, or right ventricle

18. Troponin
• Serial ECG is key :at first contact ,at 3hour ,at 6hour
• Quantitive :
• hS-Tp=00-0.02nano gram /ml
• Kit test (Qualitive ):>40 nano gram /ml
• Routine quantitative :>give the value if it is >40 nano gram /ml (ROCHE’s Lab)

19. IMAGING
• ECHO
• MRI
• SPECT

20. CT CORONARY ANGIO IN ACUTE MI
• Only when in the presentation is quite atypical
• To rule out CAD

21. TREATMENT PRINCIPLE
• Diagnosis of ACS : Universal 4th Definition of MI
• Relief from Angina : Sublingual Nitroglycerin (5mg)/ Morphine /
Pentazocine
• Monitoring vitals
• Reperfusion strategy :TLT VS PCI
• Antiplatelet therapy : Ecosprin is must and others
• Statin therapy : High dose
• Anticoagulation (UFH,LMWH,Fondaparinux)
• Beta blocker therapy, ACEI: Depending upon BP

22. Initial Management
• Care for ABC
• Oxygen if O2 saturation < 92%
• Treat VT/VF according to ACLS protocols
• Aspirin 325 mg (non-enteric coated) to be chewed

23. Thrombolysis in MI

24. Contraindication for TLT
• Absolute :IC bleed
• Relative :Pregnancy ,HTN

26. thrombolytic
regimens for
acute ST elevation
myocardial
infarction

27. • Give oral antiplatelet therapy (in addition to aspirin) to all
patients:
• 1. Patients treated with fibrinolytic therapy: Give clopidogrel loading dose 300
mg if age 75 years or less; if age over 75 years, give loading dose of 75 mg
• 2. Patients treated with no reperfusion therapy: Give ticagrelor loading dose
180 mg.
• 3. Patients treated with primary PCI: Give ticagrelor loading dose of 180 mg or
prasugrel loading dose of 60 mg (if no contraindications: prior stroke or TIA, or
relative contraindications for prasugrel such as those age 75 years or older,
weight less than 60 kg). For patients at high risk of bleeding or those for whom
prasugrel or ticagrelor cannot be used, we give clopidogrel 600 mg.
• Give anticoagulant therapy to all patients
• 1. For patients treated with primary PCI, we prefer UFH to bivalirudin.
• Dosing of UFH: An initial IV bolus of 50 to 70 units/kg up to a maximum of 5000
units. Additional heparin may be given in the catheterization laboratory based on
the results of ACT monitoring.
• Dosing of bivalirudin: Initial bolus of 0.75 mg/kg IV followed by IV infusion of 1.75
mg/kg per hour; can be discontinued after PCI.
• For patients treated with fibrinolysis, we prefer enoxaparin for patients not at
high bleeding risk or fondaparinux for those at high bleeding risk. For those
patients in whom PCI is possible or likely after fibrinolytic therapy, UFH is
reasonable.

28. • Dosing of enoxaparin
• Patients <75 years: Loading dose of 30 mg IV bolus followed by 1 mg/kg subcutaneously
every 12 hours; maximum of 100 mg for the first two subcutaneous doses. The first
subcutaneous dose should be administered with the IV bolus.
• Dose adjustment for renal impairment (CrCl <30 mL/minute)*: Loading dose of 30 mg IV followed by 1
mg/kg subcutaneously every 24 hours. The first subcutaneous dose should be administered with the
IV bolus.
• Patients ≥75 years: No IV loading dose. Administer 0.75 mg/kg subcutaneously every 12
hours; maximum of 75 mg for the first two doses.
• Dose adjustment for renal impairment (CrCl <30 mL/minute)*: No IV loading dose. Administer 1 mg/kg
subcutaneously every 24 hours.
• Supplemental IV bolus dose for patients who will receive PCI after >1 dose of therapeutic
enoxaparin: 0.3 mg/kg if last enoxaparin dose was given 8 to 12 hours earlier; no
supplemental IV dose if last enoxaparin dose was within 8 hours; use UFH if last
enoxaparin dose was more than 12 hours ago.
• Dosing of UFH: IV bolus of 60 to 100 units/kg to a maximum of 4000 units,
followed by an IV infusion of 12 units/kg per hour (maximum 1000 units per hour)
adjusted to achieve a goal aPTT of approximately 50 to 70 seconds (1.5 to 2
times control).
• Dosing of fondaparinux: 2.5 mg intravenously, followed by 2.5 mg
subcutaneously every 24 hours. This drug should be avoided in CrCl <30
mL/minute.

29. • For patients not receiving reperfusion therapy, we use
enoxaparin or UFH.
• Dosing of enoxaparin: Dose same as for patients treated with fibrinolysis (refer
to section 2 above).
• Dosing of UFH: IV bolus of 50 to 70 units/kg to a maximum of 5000 units,
followed by an IV infusion of 12 units/kg per hour adjusted to achieve a goal aPTT
of approximately 50 to 70 seconds (1.5 to 2 times control)

30. Acute management of unstable angina or non-
STEMI:
• Give antiplatelet therapy (in addition to aspirin) to all
patients:
• Patients not treated with an invasive approach: Give ticagrelor
loading dose 180 mg.
• For patients managed with an invasive approach: Give ticagrelor
loading dose of 180 mg at presentation. Prasugrel loading dose of 60
mg may be used as an alternative if given after diagnostic coronary
angiography.

31. THANK YOU