Pt’s treated with B-blockers post infarction are seen to have a significant reduction in re-infraction

Adding an ACE-I dramatically reduces mortality

What about Nitrates?

And if Mg was added:

Rx d/c after MI

• A. Beta-blocker

• B. ACE-Inhibitor or if not tolerated, ARB

• C. Aspirin

• D. Lipid lowering drug- Statin

• E. Folic Acid, Vit B6, Vit B12

• F. Clopidogrel

Hemodynamic Compromise

• A. Patients who develop hemodynamic compromise (CHF, Hypotension, Cardiogenic shock) following AMI have a worse prognosis than those with little or no hemodynamic impairment.

• B. Management of hemodynamic compromise is aided by balloon flotation Swan-Ganz catheter. This catheter makes it possible to measure cardiac output and PCWP that reflect LVEDP and helps the physician adjust therapy according to the patients hemodynamic subset

Right Ventricular Infarction

• A. Nearly 50% of patients with inferior wall MI have some evidence of right ventricular ischemia or infarction (It is hemodynamically significant in only about 10% of these patients).

• B. Should be suspected with inferior MI when patient presents with a triad of hypotension, clear lung fields, and jugular venous distention (right atrial pressure greater than 10 mmHg).

Cont’d

• C. Right sided EKG should be done in patients with inferior wall myocardial infarction.

• D. Treatment– 1. Reperfusion therapy

– 2. Increasing preload by volume expansion(1 or more Liters of normal saline)

– 3. Cautious administration of Dobutamine

– 4. Diuretics and Vasodilators should be avoided

Papillary Muscle Rupture

• A. Has mortality of 80-90% with medical therapy

• B. Prompt surgical therapy indicated

• C. Intra-aortic balloon pump prior to surgery

Ventricular Septal Defect

• A. Has mortality of 50% with surgical treatment and at least 90% with medical treatment.

• B. Surgical repair and CABG

• C. Intra-aortic balloon pump prior to surgery

Rupture of LV free wall

• A. Occurs 10% of patients who die of an AMI• B. Sudden hemodynamic collapse often accompanied by

severe chest pain suggests possibility of rupture of free wall

• C. Echocardiogram diagnostic• D. Emergency pericardiocentesis and use of intra aortic

balloon pump to stabilize• E. Emergency surgery is definitive therapeutic approach• F. Event is almost always fatal even when emergency

surgery attempted

LV Aneurysm and Mural Thrombus

• A. Occurs 10% of AMI patients• B. 80% located in anterior apical segment and

result from occlusion of LAD coronary artery• C. Mural thrombus develops in about 50% of

patients with anterior apical Q wave MI usually during the first week after infarction

• D. Thrombi are uncommon in inferior wall AMI and rare in non-Q wave infarctions

Cont’d

• E. Echocardiography useful for identifying LV aneurysm and mural thrombi

• F. 4% of AMI patients have embolic events during the first week after infarction

• G. There is a 5-fold increase in embolic events in patients with anterior apical MI’s found to have a mural thrombus by echo

Cont’d

• Other complications of LV aneurysms are CHF and ventricular aneurysms

• H. Treatment- anticoagulation with Heparin followed by Warfarin for 3-6 months significantly decreases frequency of embolic events

Using Dipi Tc99m MIBI imaging to stratify patients at risk for an event within the year

Assessment of Resting LV function

• A. Prognosis following AMI is related to degree of LV disfunction.

• B. Evaluation is done by echocardiogram, radionuclide imaging (MUGA study), positron emission tomography.

• C. Identify stunned and hybernating myocardium

Non-Invasive Strategies for Identifying Risk of Sudden Death

• A. Holter moniter- PVC’s, nonsustained ventricular tachycardia

• B. Signal averaged EKG• C. Heart rate variability• D. Patients at high risk of non-sustained V-

tach, low EF(less than 40%) consider electrophysiologic testing and implantable cardioverter defibrillator (AICD)

Cont’d

• E. Multi-center automatic defibrillator implantation trial revealed (MADIT trial)– 1. LV dysfunction less than 35%– 2. Asymptomatic non-sustained V-tach (3

beats-30 beats)– 3. Inducible, sustained, non-supressible V-tach

Patients with these criteria had improved survival with AICD.

CHD really is worth preventing

At the end…..

• The acute coronary event (AMI) can be devastating…as clinicians lets do our part to try and prevent these events from occurring.

• Remember the old saying…

• “An once of prevention is worth a pound of cure