Acute Myocardial Infarction

ACP

Pathogenesis
- Rupture and bleeding from a atherosclerotic plaques rich in foam cells
(Lipid laden macrophages)
- 70% obstruction required to produce symptoms

Diagnosis
- Must be present: 1. Clinical History 2. EKG changes 3. Elevation of
enzymes
- Heaviness, pressure, squeezing or tightness pain
- Radiation to arms, jaw and neck
- Nausea, vomiting and Diaphoresis p/pal in patients with inferior MI
- 50% of elderly patients present only with shortness of breath (SOB)

Physical Exam
- Appears anxious and in distress
- Sinus tachycardia, hypotension, tachypnea 2ary to anxiety
- JVD in case of right failure
- Chest auscultation usually normal. Rales in case of associated CHF
- S4 can be audible
- Splitting of S2 in case of LBBB

EKG
- ST elevation + MI clinical context = > 90% Probability of MI
- ST Depression or T wave inversion or New BBB are less specific
- 50% of patients with MI do not have ST segment elevation
- Patients with MI and without EKG changes = Best prognosis

LAB Findings:
- CK and CK-MB usually require more than 3hrs of ischemia to be +
- Do NOT delay treatment in patients with clinical MI and normal enzymes
- Troponin is cardiac specific marker

Imaging Studies
- Echocardiography
o Regional wall motion abnormalities occurs after seconds of
ischemia
o However wall motion abnormalities are not specific to MI and could
be secondary to ischemia or prior infarction
o Echo is useful in patients with BBB, unspecific EKG changes or
atypical symptoms
- Radionuclide imaging
o Perfusion imaging in the ED has been shown to be both sensitive
and specific in patients who’s diagnosis is uncertain.
Therapy
- Patients should be evaluated in 10 min after arrival to ED
- Check vital signs
- Check EKG
- Analgesia (IV Morphine)
- Oxygen by nasal canula
- Oral aspirin
- Sublingual NTG if BP is > 90 mmHg
- In ISIS-2 ASA was found to be as effective as streptokinase, reducing 30
day mortality by 23%
- ASA should be maintained indefinitely
- Reperfusion therapy
o Time of administration is critically. Should not exceed more than 60
min after the arrival of the patient to the ED
o Ideally less than 30 min

Killip Classification

I No Clinical Heart Failure

II Findings consistent with mild or moderate heart failure (S3 gallop, bilateral
rales in up to 50% of lung fields
III Pulmonary edema, rales in all lung fields, mitral regurgitation
IV Cardiogenic Shock

- PCI (Percutaneous coronary intervention) therapy indicated for all patient

with ST elevation who presents within 12 hr of onset of symptoms
- If PCI not available, thrombolytics should be the first choice
- Patients that were thrombolized do not require PCI unless they are
hemodynamically unstable

Indications for PCI without ST elevation:

- Recurrent angina or ischemia at rest
- Elevated levels of Troponin I
- New ST segment depression
- Recurrent angina + CHF symptoms
- High risk findings on non invasive stress test
- Depressed LV function < .40
- Hemodynamic instability
- Sustained VT
- PCI within 6 months
- Prior CABG
Thrombolysis
- Reduce mortality in 29% of patients with ST segment elevation treated
within 6 hrs after the onset of chest pain
- Thrombolysis is recommended for patients with ST elevation and less than
6 hrs after onset of chest pain
- Patients with presentation within 6-12 hrs after onset of symptoms are
also candidates but risk vs benefits should be weighed
o Contraindications:
 Intracerebral bleeding
 GI Bleeding or recent surgery
 Relative: Advanced age, low weight, HTN, Warfarin

- GUSTO-1 compared Streptokinase vs TPA (Tissue plasminogen activator)

- TPA (Ateplase®) is a little bit better but much mire expensive than
Streptokinase
- Streptokinase is CONTRAINDICATED in patients who received it before
the formation if Antibodies against Streptokinase will be present
- Rt-PA (Reteplase®): Recombinant tissue plasminogen activator is easier
for administration and can be given at the same time with IV heparin and
ASA

Combination Therapy
- Defined as the usage of Thrombolytic agent + Glycoprotein IIb-IIIa
(Abciximab®) is not clear

PCI
- Is the preferred treatment for acute MI
- Has lower mortality, reinfarction and stroke than Thrombolysis

Antiplatelet Therapy
- ASA should be given as soon as possible
- Clopidogrel should be given to all patients after PCI. Should be given
initially as 300mg dose then 75 mg/day
- Glycoprotein IIb-IIIa inhibitor (Abciximab). Recommendation IIb to give it
before PCI in patients with STEMI.
- CADILLAC study showed that abciximab is beneficial reducing major
adverse events in patients with PCI and Stent
- No evidence of improvement with Abciximab in patients with ballon
angioplastia without stent.

CABG (Coronary artery bypass graft)

- Reserved for patient in whom immediate angiography reveals coronary
anatomy that precludes PCI
- For patients in whom PCI has failed
- Patients with ventricular septal defect
- Patients with severe mitral regurgitation or myocardial rupture
Rescue Coronary Angioplasty
- Only 30-60% of patients with Thrombolysis has restoration of anterograde
flow 90min after therapy
- Rescue angiography: PCI for patients without restoration of anterograde
flow after 90 min of thrombolytics therapy
- Rescue angioplasty offers benefits but studies results are not compelling.

Intravenous Heparin
- Indicated after Thrombolysis.
- Should be always administered after rt-PA is used. Data not clear about
using it after Streptokinase.
- Although heparin is recommended in all patients to prevent formation of
apical mural thrombus and embolization.
- Optimal duration is not clear
- Recommended to give between 3-5 days

Low molecular weight heparins

- Easy to administer and lower risk of heparin induced thrombocytopenia
(HIT)
- Improve rates of reperfusion when combined with rt-PA

Beta Blockers
- Should be administered to all STEMI patients
- Reduce infarct size, HR, BP and O2 demand
- Should begin in the ED by IV administration

ACE inhibitors
- All patients with EF < 40% should receive ACE inhib
- Treatment should begin within the first 48 hrs after onset of symptoms

IV Nitroglycerin
- Seems that no benefit in patients who receive early thrombolytics therapy
- Beneficial in patients with persistent symptoms after reperfusion therapy

Prophylactic antiarrythmics
- Increase mortality
- No antiarrythmics are indicated as prophylaxis

Statin Therapy
- Should be started prior hospital discharge in all patients
- Cholesterol should be measured 24 hrs after episode
- Early initiation of statins is more beneficial than late
Calcium channel antagonists
- Should not be routinely administered
- Verapamil and diltiazem may be useful in patients with preserve LV
function and NO heart failure in whom contraindication for B-blockers
exists.

Right Myocardial infarction

- Elevated JVD and signs of right vent disfunction
- Volume therapy
- Nitrates and diuretics should be avoided
- If refractory to volume dopamine should be used

AICD
- Indicated in patients with EF < 30% after MI
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