‫إعداد و تقدي طلب سنة سادسة‬

‫معاذ عيّاد – يزيد جبيل ‪ -‬سهر العلي‬

Objectives
New Universal Definition of MI and Its Types.
Epidemiology, Pathophysiology and Risk
Factors.
Clinical features, Investigations and
Diagnosis.
Management.
Prevention.
Complications
Prognosis.
 Introduction
 The Universal Definition of Acute Myocardial Infarction states that
the term Myocardial Infarction should be used when there is evidence of
myocardial necrosis in a clinical setting consistent with myocardial
ischemia.
 Classification of Myocardial Infarction:
o Type 1: Spontaneous Myocardial Infarction related to ischemia due to
primary coronary event such as plaque erosion or rupture, fissuring or
dissection.
o Type 2: Myocardial Infarction due to secondary ischemia due to imbalance
between oxygen demand and supply. eg, coronary spasm, anemia, and
hypotension.
o Type 3: Sudden cardiac death with symptoms of ischemia, accompanied
by ST elevation or LBBB, or verified coronary thrombus by angiography or
autopsy, but death occurring before blood samples could be obtained.
o Type 4 a: Myocardial Infarction associated with PCI.
o Type 4 b: Myocardial Infarction associated with verified stent thrombosis.
o
Epidemiology

1
6. 3
5 0. 2. 2
%
4. 7 4 %
21.2 3 % %
% %
Epidemiology

38
1.
.5 23
7
% .1
30 %
4. %
.8
1. 3
%
7 %
%
Pathophysiology
 Causes and Precipitating
Factors
Fixed Potentially
2.Age changeable:
2. Hyperlipidaemia
3.Male sex
3. Cigarette smoking
4.Positive family history 4. Hypertension
5.Deletion polymorphism in the
5. Diabetes mellitus
ACE gene (DD) 6. Obesity
7. Lack of exercise
8. Blood coagulation factors
9. Homocysteinaemia
10.Gout
11.Contraceptive pill
Clinical presentation
History:
o Chest pain (discomfort) described as substernal
central squeezing, aching, burning, or even
sharp pain.
o Shortness of breath
o Atypical presentations 20%.
o Family H’x.
o Risk factors in Past, social and
personl H’x.
o Other associated symptoms.
Clinical presentation. cont
Physical examination
o Low-grade fever
o Hypotension or hypertension
o Fourth heart sound (S4)
o Dyskinetic cardiac bulge
o Systolic murmur
o Signs of congestive heart failure (CHF ).
o Other findings include cool, clammy skin and
diaphoresis.
Differentials
Pulmonary embolism
Aortic dissection, aortic stenosis.
Spontaneous pneumothorax
Acute Pericarditis or Myocarditis.
Reflux oesophagitis, oesophageal spasm.
Acute gastritis or Cholecystitis.
Anxiety disorders and others.
Investigations
The
electrocardiogram
(ECG) is the most
important tool in the
initial evaluation , it
confirms diagnosis of
.80%

Cardiac Biomarkers :
Troponin levels &
Creatine kinase. level
Investigations.cont
.Myoglobin levels
.Complete blood cell count 
.Chemistry profile 
.Lipid level profile 
C-reactive protein (CRP)
.levels

Chest radiography o
Echocardiography o
Myocardial perfusion o
imaging
Cardiac angiography o
ECGexample
ECGexample
 Management
Prehospital Phase:
All patients being transported for chest pain should be
managed as if the pain were ischemic UNTIL PROVED
OTHERWISE.
Treatment of patients with suspected STEMI with
morphine, oxygen, nitroglycerin, and aspirin (AHA
recommended).
Specific prehospital care includes the following:
o IV access, supplemental oxygen, pulse oximetry.
o Immediate administration of aspirin en route.
o Nitroglycerin for active chest pain, given sublingually or by
spray.
o Telemetry and prehospital ECG, if available.
 Management cont.
Hospital Phase:
2. The evaluation of patients with chest pain begins with a 12-
lead ECG even as the physician is beginning a focused
history, including contraindications to fibrinolysis, and a
targeted physical examination.
3. Patients with confirmed no ST-segment elevation are not
candidates for immediate thrombolytics but should receive
anti-ischemic therapy.
4. Treatment is aimed at:
o Restoration of the balance between the oxygen supply and
demand to prevent further ischemia.
 Management cont.
The decision as to whether the patient will be
treated with thrombolysis or recanalization (CABG
or primary PCI) should be made within 20 minutes
upon arrival.
All patients should be monitored, two large-bore
IVs, pulse oximetry and oxygen should be given. A
chest radiograph should be obtained.
 Management cont.
Pharmacologic intervention:
Aspirin should be administered immediately (162 to
325 mg). Use clopidogrel in case of aspirin allergy.
IV heparin:
1. Initial bolus 60 IU/kg, maximum, 4000 IU.
2. Then 12 IU/kg/hour, maximum 1000 IU/hour, adjusted to
maintain aPTT=1.5 to 2 times the control value) or LMWH
(enoxaparin) 30 mg intravenous bolus, then 1 mg/kg SC
b.i.d.
 Patients with chest pain should be given sublingual
nitroglycerin (0.4 mg every 5 minutes for a total of three
 Management cont.
Pharmacologic intervention:
Persistent ischemic pain may be treated with titrated
to IV doses of morphine (2 to 4 mg repeated every 5
to 15 minutes).
Initiation of ß-blocker therapy (The best is Metoprolol
5 mg IV every 5 min 3 times; titrate to heart rate and
SBP) is usually indicated, especially in patients with
hypertension, tachycardia, and ongoing pain;
however, decompensated heart failure is a
contraindication to the acute initiation of ß-blocker
therapy, particularly by the intravenous route.
 Management cont.
Pharmacologic intervention:
An ACE inhibitor (Captopril 6.25 mg PO tid) should be
given within the first 24 hours to patients with
anterior MI, pulmonary congestion, or LVEF<40% in
the absence of hypotension. If intolerant, an
angiotensin receptor blocker (valsartan or
candesartan) should be administered.
The ideal systolic blood pressure is 100 to 140 mm
Hg. Excessive hypertension responds to titrated
nitroglycerin, ß-blocker therapy, and morphine.
Relative hypotension could require discontinuation of
 Complications
 Complications:
 ARRHYTHMIAS: Sinus bradycardia, Supraventricular tachyarrhythmias,
Ventricular arrhythmias, Conduction disturbances.
 MYOCARDIAL DYSFUNCTION: Acute left ventricular failure, Hypotension
and shock.
 RIGHT VENTRICULAR INFARCTION.
 MECHANICAL DEFECTS: Partial or complete rupture of a papillary muscle or
of the interventricular septum occurs in less than 1% of acute myocardial
infarctions and carries a poor prognosis.
 MYOCARDIAL RUPTURE.
 LEFT VENTRICULAR ANEURYSM.
 PERICARDITIS.
 MURAL THROMBUS.
 Prevention
 Cigarette smoking
 Hypertension: achieve a goal of less than 140/90 mm Hg.
 Diabetes mellitus: goal of normal fasting plasma glucose
(<125 mg/dl).
 Hyperlipidemia: HDL <40 mg/dl, family history of premature
coronary heart disease, or age (>45 years for men, >55
years for women)], the LDL goal for primary prevention is
less than 160 mg/dl. If multiple risk factors are present, the
LDL goal is less than 130 mg/dl.
 Obesity: body mass index of less than 25 kg/m 2.
 Physical activity for at least 30 minutes/day
 Prognosis
Acute MI is associated with a 30% mortality rate;
half of the deaths occur prior to arrival at the
hospital.
An additional 5-10% of survivors die within the first
year after their MI.
Approximately half of all patients with an MI are
rehospitalized within 1 year of their index event.
Overall, prognosis is highly variable and depends
largely on the extent of the infarct, the residual LV
function, and whether the patient underwent
References
Cecil Medicine, 23rd Ed
Harrison's Principles of Internal Medicine, 17th
Edition, 2008
eMedicine.com Specialties > Endocrinology >
Diabetes Mellitus
 Thank You
Any Questions ?