Practitioner Education Course

Transcription

1 2015 Practitioner Education Course

2 ST Elevation Myocardial Infarction 2

3 Pathology Concept of vulnerable plaque Mild Atheroma Diagnosis IVUS OCT 3

4 Diagnosis This is based on : Clinical History ECG Changes. Raised enzyme measurement. 4

5 Aspects of diagnosis 5

6 Progressive ECG changes 6

7 Raised enzyme measurements Troponin T and I Creatine Kinase brain. CK Mb Reperfusion therapy. Ht, skeletal muscle & Pt with skeletal M. damage. LDH for late diagnosis ( last for 1-3 w ) 7

8 Changes in serum enzyme activity 8

9 Differential Diagnosis Massive Pulmonary Embolism Symptoms Pain, S.O.B. The ECG characteristic abnormalities Markers D. dimer. Imaging Spiral C.T. scanning 9

10 Differential Diagnosis Acute Pericarditis : Pain preceded by pyrexia. Character of pain with inspiration ECG widespread changes, ST (concave.) Enzyme changes Not present. 10

11 Differential Diagnosis Dissecting aneurysm : Pain ECG usually No changes Imaging TOE, CT, MRI 11

12 Treatment of Acute infarction Immediate treatment Aspirin Reperfusion Therapy Thrombolysis Angioplasty Beta-blockers Other drugs 12

13 Treatment of Acute infarction 1.Immediate therapy Admission to CCU ( resuscitation, defibrillation, temporary pacing ) Relief of pain. Treatment of unwarranted anxiety. O2 therapy when needed. 2.Aspirin therapy : Mortality after AMI by % mg tab. Should be given as early as possible. 13

14 Indications for thrombolysis Patients with ST segment elevation New onset of BBB Look for benefit risk ratio Not indicated in Unstable Angina or NSTEMI 14

15 Timing of thrombolytic therapy As early as possible. The time window for success < 4 h In Pts with persistent chest pain up to 12 h. Complications : Intracerebral Bleeding G.I.T Thrombolysis in the elderly. 15

16 B. Physical reperfusion (coronary angioplasty) Always preferable than thrombolysis. Time window: within 3-4 h. Suitable for pts with : contraindications to thrombolysis. Salvage or rescue PCI. Coronary angio: after thrombolysis. 16

17 . 3Other drugs Beta-blockers mortality by. % 20 ACEIS to prevent remolding in sizable infarctions Statins for hypolipedimic & pleotrophic effects. 17

18 Prognosis In ¼ of all episodes of MI death occur suddenly. The risk of death is higher in the first few hours. The risk of death depends on age, previous MI, comorbidity and extent of infarction. 18

19 Bad Prognostic signs Persistent tachycardia. Continuing gallop rhythm. Rt. sided failure. Bundle branch block. Atrial fibrillation. 19

20 Complications Disturbance of rate, rhythm & conduction : Ventricular arrhythmia Reperfusion Atrial arrhythmia A.F Brady arrhythmia C.H.B Bundle branch block Poor Prognosis Ht failure & cardiogenic shock : Ht failure PCW < 20 mmhg Cardiogenic shock Reversible arrhythmia, hypervolemia, RV infarc,. mechanical complications Persistent IAP, immediate PCI. 20

21 Mechanical Complications V.S.D Papillary muscle rupture. Cardiac rupture. Other complications : Pulm. embolism & infarction Systemic arterial embolism. Cerebrovascular accidents. Pericarditis.. 21

22 Late Complications Infarction expansion Vent. Thinning, wall tension (ACEI ) Ventricular aneurysm Formation H.F., embolism, arrhythmias. Late arrhythmias delayed conduction, reentry circuit. 22

23 Ventricular arrhythmias 23

24 Risk Stratification at hospital discharge The prognosis is best in the absence of HT, H.F & angina. % 90of Pts survive < 1 Y & 25 % survive < 20 Y The risk of recurrent infarction & sudden death with time. 24

25 Long term Prognosis is determined by three factors Assessment of LVF : Echocardiography radionuclide imaging. Assessment of schema coronary angio Exercise testing Assessment of electrical instability Holter monitor high resolution ECG H.R Variability & measures of autonomic dysfunction. 25

26 Drug treatment at discharge A number of drugs improve long term prognosis Every pt. post interaction should be considered for these therapies These drugs include : Beta blockers : It mortality rate by. % 20 It mainly incidence of sudden death. The potential benefit is greatest in those at greater risk. It also improve prognosis in pts with LVD& H.F 26

27 ACE inhibitors ACE inhibitors long term mortality after M.I. Pts who benefit most are the following groups : Pts with moderate or large ant. Infarction Pts with LVD ( Ef > 40 % ) & those with segmental abnormalities. Pts with clinical H.F 27

28 Statins Lowering cholesterol level recurrent coronary events. Aggressive lowering of cholesterol is recommended post M.I. The benefit of cholesterol is obtained irrespective of the initial level. Treatment is usually for life. 28

29 Aspirin Aspirin therapy is recommended in Pts with established CAD mortality by % 20 Aspirin should be continued for life. 29

30 Cardiac Rehabilitation After M.I Pts are often anxious about their future. Cardiac rehabilit Program: restore confidence & sense of well being. Rehabilit. Program include: Ex. program, counseling for LSM, preventive measures, These include the following : Exercise : Pt should exercise for 30 m at least 3 times / week. They should exercise to around 75 % of maximal H.R (220-age) 30

31 Other measures Smoking Pt. must stop smoking completely. Smoking The risk of the reinfarction & S.D Diet Over Wt. Pts should be encouraged to lose weight. Diet should contain low animal fat Return to work Most of Pts return to work in less than 2 m. Some occupations like airline pilot cannot continue. Bus drivers return to work after meeting certain criteria 31

32 Other measures Sex Sexual intercourse better to be avoided for 1 m. E.D can be related to medication or psychological factors. Pts taking nitrates should not use sildenafil. Travel Travelling abroad should be prohibited for at least 1m. Pts may need appropriate medical insurance cover after M.I 32

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