Acute Management of Myocardial

Infarction
 Introduction

• Stable angina
• Acute coronary syndrome
– STEMI
– NSTEACS
• NSTEMI
• Unstable angina
 Introduction

• Stable angina arise when lumen stenosis >70% →

impaired blood supply to heart only during on exertion or
increased metabolic demand
• Acute coronary syndrome arise when vessel becomes
occluded by thrombus
– Unstable angina – when atherosclerotic plaque shoot
of embolus downstream to cause microinfarct
– NSTEMI – when necrosis confined to endocardial
layers (most susceptible to ischaemia)
– STEMI – when full thickness necrosis of the
ventricular wall occurs
 Atherosclerosis – Time line

Dr.Sarma@works 5
Endothelial NO Balance

NO

6
• Angina stabil timbul ketika stenosis lumen> 70% →
mengurangi suplai darah ke jantung hanya pada saat
beraktivitas atau meningkatnya kebutuhan metabolik.
• Sindrom koroner akut timbul saat pembuluh darah
tersumbat oleh trombus
– Angina tidak stabil - saat plak aterosklerotik
menyebabkan embolus ke hilir menyebabkan
microinfarct
– NSTEMI - bila nekrosis terbatas pada lapisan
endokard (paling rentan terhadap iskemia)
– STEMI – bila ketebalan nekrosis penuh pada dinding
ventrikel
 Introduction

• Stable angina – normal ECG, normal troponin

• Unstable angina – normal troponin
• NSTEMI – elevated troponin
• STEMI – elevated ST segment
 History

• All causes central crushing chest pain or tightness radiating

to arm, neck and jaw
• Stable angina usually last less than 20 minutes,
precipitated by exertion and relieved by rest or nitrates
• ACS usually lasts more than 20 minutes, sudden onset
usually at rest and not relieved by rest
• All associated with sx of ↓cardiac output – SOB, presyncope
or syncope, palpitations
• All associated with sx of sympathetic activation – nausea,
vomiting, sweating, pale, clammy
• All associated with risk factors – HTN, high cholesterol, DM,
smoking, family history
• Semua penyebab nyeri dada atau nyeri dada sentral
memancar ke lengan, leher dan rahang
• Angina stabil biasanya berlangsung kurang dari 20 menit,
dicetuskan oleh kegiatan dan lega karena istirahat atau
pemberian nitrat
• ACS biasanya berlangsung lebih dari 20 menit, onset
mendadak biasanya saat istirahat dan tidak lega karena
istirahat
• Semua berhubungan dengan sx ↓ curah jantung - SOB,
presyncope atau sinkop, palpitasi
• Semua berhubungan dengan aktivasi simpatik - mual, muntah,
berkeringat, pucat, berkeringat
• Semua terkait dengan faktor risiko - HTN, kolesterol tinggi,
DM, merokok, riwayat keluarga
 Investigations

• Resting ECG (on arrival)

– Stable angina – normal
– Unstable angina or NSTEMI – ST depression or T
wave inversion
– STEMI – ST elevation → Q wave (permanent) → T
wave inversion (in this order)
• Cardiac enzymes – Troponin, CKMB/CK ratio, AST,
LDH
– Stable angina and unstable angina – normal
– NSTEMI, STEMI – raised
 Acute Management

• Oxygen therapy
• GTN (½ sublingual tab)
• Aspirin 300mg
• IV morphine 2.5~5mg + IV metoclopramide 10mg
 Hospital Management

• Aspirin, GTN, morphine, oxygen if not already given

• Monitor oximetry, BP, continuous ECG
• 12 lead ECG, IV access, cardiac enzyme
 STEMI

• Subsequent management (start during this hospital admission)

– Statins, aspirin and clopidogrel, ACEI (or ARB), β-blocker (if
CI then CCB)
– Anticoagulation therapy to prevent thromboembolism
(warfarin for 6mos if large anterior MI, esp if echo show large
akinetic/dyskinetic area, aneurysm or mural thrombus)
– Nitrates PRN
– Cardiac rehabilitation
• Antiplatelet post stent
– Aspirin for life
– Clopidogrel for at least 6wks for metal stent
– Clopidogrel for at least 12mos for drug eluting stent
– Drug eluting stent have lower early re-stenosis rate c.f. bare
metal stent however have a problem of late thrombosis
 UA and NSTEMI

• Stabilize acute coronary lesion

– Anti-platelet (aspirin and clopidogrel ± GPIIb/IIIa inhibitor)
– Anti-thrombin (UFH or LMWH)
– Anti-ischaemia (β-blocker if CI then CCB, consider
nitrates, morphine)
• High risk – urgent angiography ± PCI
• Low risk – arrange stress tests
• Subsequent management (start during this hospital
admission)
– Statins, aspirin and clopidogrel, ACEI (or ARB), β-
blocker (if CI then CCB)
– Nitrates PRN
– Cardiac rehabilitation
 Stable Angina

• Statins, aspirin (or clopidogrel), ACEI, β-blocker

• Nitrates – sx relief or prophylaxis (patch or tablets but
must have 8h nitrate free period/day)

Wholistic care (all IHD):

• Lifestyle change – quit smoking, eat healthy, exercise
more, avoid excessive exertion or stress
• Risk factor control – HTN, high cholesterol (keep
<4mmol/L), DM
• Assess depression, level of support