Management of Acute Myocardial Infarction

Sivanandam Vasudevan Sivanandam Vasudevan

Management of Acute Myocardial Infarction

• Pre Hospital PhasePre Hospital Phase

• ERER

• CCUCCU

• Step-down - TelemetryStep-down - Telemetry

• Post Hospital PhasePost Hospital Phase

Complications of Acute Myocardial Infarction

• Arrhythmic ComplicationsArrhythmic Complications

• Mechanical ComplicationsMechanical Complications

• Ischemic ComplicationsIschemic Complications

• Miscellaneous ComplicationsMiscellaneous Complications

[DVT, PE, Pericarditits, TPA complications, [DVT, PE, Pericarditits, TPA complications, Pneumonia]Pneumonia]

Arrhythmic ComplicationsArrhythmic Complications[Early < 24 hrs & late >24 hrs][Early < 24 hrs & late >24 hrs]

• Ventricular – PVC, V tach/V FibVentricular – PVC, V tach/V Fib

• Atrial – PAC, SVT, A Fib Atrial – PAC, SVT, A Fib

• Bradycardia – SinusBradycardia – Sinus

• AV block – Complete Heart BlockAV block – Complete Heart Block

• LAFB, LPHB, LBBB & RBBBLAFB, LPHB, LBBB & RBBB

Mechanical Complications of Acute Myocardial Infarction

• Papillary Muscle Rupture – Acute MRPapillary Muscle Rupture – Acute MR

• Ventricular Septal Defect Ventricular Septal Defect

• Right Ventricular MIRight Ventricular MI

• Free Wall RuptureFree Wall Rupture

• Cardiogenic shockCardiogenic shock

• Cardiac TamponadeCardiac Tamponade

Hemodynamic findings in complications causing Hemodynamic findings in complications causing cardiogenic shock with acute MI (a)cardiogenic shock with acute MI (a)

• Ac Pul Ac Pul edemaedema

• ShockShock

• MRMR

Mechanisms causing MR during an acute MI and their Mechanisms causing MR during an acute MI and their treatment modalitiestreatment modalities

Rupture of papillary Rupture of papillary muscle, a rare complication muscle, a rare complication of acute MI (a)of acute MI (a)

Rupture of papillary Rupture of papillary muscle, a rare complication muscle, a rare complication of acute MI (b)of acute MI (b)

Transesophageal echocardiogram in the four-chamber Transesophageal echocardiogram in the four-chamber viewview

Hemodynamic findings in complications causing Hemodynamic findings in complications causing cardiogenic shock with acute MI (b)cardiogenic shock with acute MI (b)

• Ac Pul Ac Pul edemaedema

• ShockShock

• Systolic Systolic murmurmurmur

Ventricular Rupture [VSR]Ventricular Rupture [VSR]

Ventricular septal rupture (a)Ventricular septal rupture (a)

Ventricular septal rupture (b)Ventricular septal rupture (b)

Hemodynamic findings in complications causing Hemodynamic findings in complications causing cardiogenic shock with acute MI (c)cardiogenic shock with acute MI (c)

• CHFCHF

• Clear lungsClear lungs

• HypotensionHypotension

• Systolic Systolic murmurmurmur

• Inf. MIInf. MI

ECG V4 RECG V4 R

Hemodynamic findings in complications causing Hemodynamic findings in complications causing cardiogenic shock with acute MI (d)cardiogenic shock with acute MI (d)

Hemodynamic findings in complications causing Hemodynamic findings in complications causing cardiogenic shock with acute MI (e)cardiogenic shock with acute MI (e)

• BP < 90BP < 90

• TachycardiaTachycardia

• Pul edemaPul edema

• ConfusedConfused

• Skin cold Skin cold clammy clammy

• Ant. MIAnt. MI

• Mortality 80%Mortality 80%

Regional acute MI, infarct expansion, chamber Regional acute MI, infarct expansion, chamber thrombosis and aneurysm formation (a)thrombosis and aneurysm formation (a)

Regional acute MI, infarct expansion, chamber Regional acute MI, infarct expansion, chamber thrombosis and aneurysm formation (b)thrombosis and aneurysm formation (b)

Regional acute MI, infarct expansion, chamber Regional acute MI, infarct expansion, chamber thrombosis and aneurysm formation (c)thrombosis and aneurysm formation (c)

Regional acute MI, infarct expansion, chamber Regional acute MI, infarct expansion, chamber thrombosis and aneurysm formation (d)thrombosis and aneurysm formation (d)

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CT of patients with stroke as a complication of MI (a) B

© 2003 Science Press I nternet Services

CT of patients with stroke as a complication of MI (c)CT of patients with stroke as a complication of MI (c)

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CT of patients with stroke as a complication of MI (d)

© 2003 Science Press I nternet Services

CT of patients with stroke as a complication of MI (e)

Incidence of cardiogenic shock complicating acute MIIncidence of cardiogenic shock complicating acute MI

Incidence of cardiogenic shock complicating acute MI

INCIDENCE OF MECHANICAL,

CAUSES &percnt;

STUDY

OVERALL INCIDENCE OF CARDIOGENIC SHOCK

(INCIDENCE ON PRESENTATION), &percnt;

LV FREE WALL

RUPTURE

ACUTE VSR

ACUTE MR

Prethrombolytic era

Killip and Kimball &lsqb;6&rsqb;

19 - - -

Scheidt &lsqb;4&rsqb;

15 - - -

Hands et al. &lsqb;3&rsqb;*

7.1 - - -

Goldberg et al. &lsqb;5&rsqb;†

7.5‡ (3.2§) - 0.9 3.9&percnt;

Thrombolytic era

GISSI-1 &lsqb;20&rsqb;

-(2.4) - - -

LATE &lsqb;21&rsqb;¶

- 3.4 - -

TIMI-II &lsqb;18&rsqb;

5.8 (1.5) - - -

ISIS-3 &lsqb;17&rsqb;

7.0 1.3 - -

GUSTO &lsqb;19&rsqb;

6.1 (0.8) - 0.5 1.7

*Excludes patients with shock on presentation.

†14&percnt; received thrombolytics.

‡1976-1988: incidence unchanged.

§Within 24 hours of presentation.

¶Includes all known and suspected cases of rupture.

Rupture of the heart complicates acute MI in about 10% Rupture of the heart complicates acute MI in about 10% of casesof cases

Ischemic Complications Post Myocardial InfarctionChest pain Post MI

• Recurrent anginaRecurrent angina

• Recurrent MIRecurrent MI

• Pericarditis[ Acute & DresslerPericarditis[ Acute & Dressler’’s ]s ]

• PneumoniaPneumonia

• Pulmonary EmbolismPulmonary Embolism

• Shoulder hand syndromeShoulder hand syndrome

CT of patients with stroke as a complication of MI (a)

Management of Acute Myocardial Infarction

Pre discharge work upPre discharge work up

• Secondary prevention – Diet, Exercise, Secondary prevention – Diet, Exercise, Weight control, Smoking cessationWeight control, Smoking cessation

• Lipid controlLipid control

• B Blockers, ACE Inhibitors, ASA, StatinsB Blockers, ACE Inhibitors, ASA, Statins

• Cardiac RehabilitationCardiac Rehabilitation

• Discharge planningDischarge planning

• Pre discharge ECHO, Stress testPre discharge ECHO, Stress test

Management of Acute Myocardial Infarction

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