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Clinico-pathologicalconference
1st
Myocardial
infarctionPresentation by
1605- Abubakkar
Raheel
1622- Haider Ali
1606- Ahme...
Long Case
• Muhammad Shareef, a 65 year old male patient from
Abbottabad, known case of Diabetes since last 12
years and C...
Dept of Medicine
Frontier Medical and Dental College
Dept of Medicine
Frontier Medical and Dental College
History of Patient
• Name: Muhammad Shareef
• Sex: Male
• Age: 65 years
• Marital Status: Married
• Occupation: Retired Go...
Chief Complaints
• Chest pain – 6 hrs
• Shortness of Breath – 6 hrs
• Vomiting - 5 hrs
Dept of Medicine
Frontier Medical a...
History of Present illness
• Known case of Diabetes - 12 yrs &
Ischemic Heart Disease – 2 yrs
• Chest pain started 6 hrs b...
History of Present illness
• Shortness of breath – 6hrs
• Sudden onset
• present at rest
• Vomiting – 5hrs
• 2 episodes of...
History of Present illness
Associated symptoms:
• Moderate fever
• Sweating
• Dizziness
• Patient was completely conscious...
History of Present illness
• Systemic Inquiry
1. General
a. Reduced apetite
b. Sleep disturbed
c. Weakness
2. Respiration
...
History of Present illness
• Alimentary system: Nausea & Vomiting
present
• Urinary system: No significant history
Dept of...
History of Past illness
• Past Medical History
– Diabetes : 12 yrs
– IHD : 2 yrs
– HTN : Positive
– TB : Negative
– Asthma...
Family History
• Positive for IHD, HTN and DM
• 2 brothers died of MI
Dept of Medicine
Frontier Medical and Dental College
Drug & treatment History
• Patient was taking anti diabetics and anti
hypertensive drugs
• Drug compliance was poor
• No o...
Personal History
• Chronic Smoker
• No history of drinking
• Sedentary lifestyle
Dept of Medicine
Frontier Medical and Den...
Socio-economic History
• Satisfactory
Dept of Medicine
Frontier Medical and Dental College
History based Differential Diagnosis
• Acute Myocardial Infarction
• Unstable Angina
• Pleurisy
• Pericarditis
• Pneumotho...
General Physical Examination
Patients general appearance
• Pale and anxious
Dept of Medicine
Frontier Medical and Dental C...
General Physical Examination
• Vitals
– B.P: 160/90mmHg in lying position
– Pulse: 115 b/m, regular, tachycardia
– Temp: 1...
General Physical Examination
• No Clubbing, pallor, splinter
hemorrhages koilonychias or leconichia
• Mild tobacco stainin...
General Physical Examination
• Jaundice not present
• Dental hygiene good
• Carotid briut not audible
• No abnormality on ...
Systemic Examination
1. CVS Systemic Examination
a. Inspection:
• No Chest deformity
• No sternotomy or any other surgical...
General Physical Examination
• Heave: well sustained (at apex)
• No left parasternal lift
c. Auscultation:
Mitral, Tricusp...
General Physical Examination
• S1- Normal (Apex)
• S2- Audible (Left sternal edge)
• No added sounds
• No murmurs
Dept of ...
General Physical Examination
c. GIT:
• Liver not palpable
• Spleen not palpable
• Ascites not present
d. Respiration:
• Ch...
General Physical Examination
e. CNS:
No remarkable findings
Dept of Medicine
Frontier Medical and Dental College
Examination based Differential Diagnosis
• Myocardial Infarction
• Unstable Angina
Dept of Medicine
Frontier Medical and D...
Investigations - ECG
Dept of Medicine
Frontier Medical and Dental College
Investigations
ECG:
Done within 25 mins of patient arrival
Findings:
• Rate: 78.9
• Rhythm: Sinus Rhythm
Dept of Medicine...
Investigations
Leads showing ECG Changes:
• V1 to V6, AvL
• Changes include:
• ST Segment Elevation
• Q wave development
•...
Investigations
• Left Axis deviation seen by thumb rule on
Lead 1 and AvF
(For inferior wall MI, changes are seen in:
Lead...
Investigations
 Cardiac biomarkers
• Trop T raised
• CK-MB raised
Chest Xray
• Cardiothoracic ratio increased showing LV...
Investigations – Xray
Dept of Medicine
Frontier Medical and Dental College
Investigations
Other Blood Tests
• ESR and CRP raised
Echocardiography could not be done due
to the non availablity of f...
Investigations based Diagnosis
Anterolateral ST Segment Elevation
Myocardial Infarction with Left Axis
Deviation
Dept of M...
Management
• Patient was immediately admitted in ICU. Within 10
mins, ECG was performed and based upon
diagnosis, followin...
Management
• Aspirin 300mg PO
• (Therapy should be continued indefinitely if there
are no side affects)
• Clopidogrel 600m...
Late Management
• Patient advised on the following:
• Lifestyle Modification:
• Lipid Lowering diet
• Cessation of Smoking...
Late Management
• Secondary Drug therapy:
• Aspirin
• B blocker
• Ace Inhibitor/ARB
• Statin
• Additional therapy for DM a...
The patient was given Streptokinase (Thrombolysis)
within 8 hours of his arrival. He is still in the ICU
undergoing 24/7 o...
What is MI ?
• Detection of rise and/or fall of cardiac biomarker
values (preferably cardiac troponin) with atleast one
of...
Types of MI
On the basis of ECG, there are two main types of MI
• STEMI (major coronary artery complete obstruction)
• Non...
Arterial Supply of the Heart
Dept of Medicine
Frontier Medical and Dental College
Arterial Supply of the Heart
Dept of Medicine
Frontier Medical and Dental College
Arterial Supply of the Heart
There are two major arteries which supply the heart
• Left coronary artery
• Right coronary a...
Arterial Supply of the Heart
2. Right Coronary Artery
It supplies RA, RV and inferio-posterior part of LV
Branches include...
Arterial Supply of SA & AV Node
• SA Node: RCA in 60% individuals
• AV Node: RCA in 90% individuals
Clinical Significance:...
Conducting system of Heart
Dept of Medicine
Frontier Medical and Dental College
Nerve Supply of Heart
• Adrenergic Nerves from the Cervical Sympathetic
chain supply atria and ventricles
• Parasympatheti...
Pathophysiology of MI
Atheromatous plaque formation
Interplaque haemorrhages
Exposure of Subendothelial
collagen fibers
Fo...
Pathophysiology of MI
Dept of Medicine
Frontier Medical and Dental College
Pathophysiology of MI
Dept of Medicine
Frontier Medical and Dental College
Pathophysiology of MI
• LCA Occlusion:
 LAD occlusion (40-50) leads to
Anterior wall infarction of LV
Anterior portion of...
Pathophysiology of MI
 RCA Occlusion (30-40%)
RCA occlusion leads to infarction of
• Posterior wall of RV
• Inferior wall...
Clinical features
 Symptoms:
• Pain: Crushing, retrosternal chest pain radiating to
back, left arm, neck or jaw
• Anxiety...
Clinical features – Pain Areas
Dept of Medicine
Frontier Medical and Dental College
Clinical features
• Signs
 Sympathetic activation:
- pallor
- sweating
- tachycardia
 Vagal activation:
-bradycardia
Dep...
Clinical features
 vomiting
• Signs of impaired myocardial function:
 Hypotention
 Narrow pulse pressure
 JVP may be r...
Clinical features
 3rd heart sound
 Quiet 1st heart sound
 Diffuse apical impulse
 Lung crepitations
Dept of Medicine
...
Clinical features
• Signs of tissue damage
 fever
• Signs of complications e.g Mitral regurgitation,
pericarditis etc
Dep...
Clinical features
• Silent MI
 diabetic patients
 Older individuals
Dept of Medicine
Frontier Medical and Dental College
Investigations
• ECG
• Cardiac biomarkers
• Chest X-Ray
• Echocardiography
• ESR & CRP
• Angiography
Dept of Medicine
Fron...
Investigations
• ECG
It is central to confirming the diagnosis but may be
difficult to interpret if there is bundle branch...
Investigations – Normal ECG
Dept of Medicine
Frontier Medical and Dental College
Investigations – Normal ECG
Dept of Medicine
Frontier Medical and Dental College
Investigations - ECG
Earliest changes are seen in ST-segment
1. STEMI
• ST-segment elevation
• progressive loss of R wave ...
Investigations - ECG
2. NSTEMI
• St-segment depression
• T-wave changes
• Loss of R-wave
• Absence of Q-wave
Dept of Medic...
Investigations – ECG - STEMI
Dept of Medicine
Frontier Medical and Dental College
Investigations - ECG
 Significance of chest leads
 Antero-septal infarct
v1 ,v2,v3,v4
 Antero-lateral
v4,v5,v6 and AVL ...
Investigations - ECG
 Inferior infarction
leads II , III and AvF
 Posterior wall infarction doesn’t cause ST elevation
o...
Cardiac Biomarkers
1. Troponins
2. Creatinine kinases
3. LDH
4. AST
5. Myoglobins
6. Most specific are troponins and CK-MB...
Cardiac Biomarkers
1. CK-MB
Rises in 4-6 hours and peaks a 12 hours and falls to
normal within 48-72 hours . It is very im...
Investigations- Chest Xray
• Chest Xray to determine cardiomegaly and
pulmonary edema
Dept of Medicine
Frontier Medical an...
Investigations - Echocardiography
• Useful for assessing ventricular function and
determining complications
Eg. Mural thro...
Investigations - Other blood tests
1. ESR raised
2. Leucocytosis
3. CRP raised
Dept of Medicine
Frontier Medical and Denta...
Management
Dept of Medicine
Frontier Medical and Dental College
Management
Dept of Medicine
Frontier Medical and Dental College
Drugs used in treatment of MI
1. Analgesics
- Opiates: Morphine Sulphate dimorphine
2. Anti-emetics: metoclopromide
3. Ant...
Drugs used in treatment of MI
b. Anticoagulants :
– LMW Heparin, HMW Heparin,
pentasaccharide - fondaparinux
– Warfarin
De...
Drugs used in treatment of MI
4. Anti anginal drugs
- Nitrates: GTN, isosorbide dinitrate
- B blockers: metoprolol and ate...
Invasive modalities used in the treatment of MI
• PCI (Percutaneous Intervention)
• CABG (Coronary Artery Bypass graft) Su...
Late Management of MI
Lifestyle modifications
Diet
Cessation of smoking
Weight control
Reguar exercise
Dept of Medicine
Fr...
Late Management of MI- Sec prevention
• Anti platelet therapy
• B blockers
• Ace inhibitors
• Statins
• Additional therapy...
Complications
• Arrythmias
• Bradycardia
• Acute Circulatory failure
• Pericarditis
Dept of Medicine
Frontier Medical and ...
Complications - Mechanical
• Rupture of papillary muscle
• Rupture of I/V septum
• Rupture of ventricle which can lead to ...
Prognosis
• If medical care is not provided, death occurs in
almost 1/4th of the cases. Half of the death occurs
within 24...
Prognosis
OF THOSE WHO SURVIVE AN ACUTE ATTACK, MORE THAN
80% LIVE FOR A FURTHER YEAR. ABOUT 75% FOR 5 YEARS.
50% FOR 10 Y...
Thankyou everyone 
Dept of Medicine
Frontier Medical and Dental Collegev
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Myocardial Infarction - Case Presentation and an Overview

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Case Presented by Final Year MBBS sudents of Frontier Medical College at the 1st Clinico-Pathological Conference for the year 2015.The Presentation is divided into two parts. First part is about a case of an Acute ST Segment elevated Myocardial Infarction with. Its management at the Hospital and the findings. Second part is about the pathophysiology, Cinical signs and symptoms and an effective gold standard treatment of MI.

Veröffentlicht in: Gesundheit & Medizin

Myocardial Infarction - Case Presentation and an Overview

  1. 1. Clinico-pathologicalconference 1st Myocardial infarctionPresentation by 1605- Abubakkar Raheel 1622- Haider Ali 1606- Ahmed Arsalan Final Year MBBS 27th February, 2015
  2. 2. Long Case • Muhammad Shareef, a 65 year old male patient from Abbottabad, known case of Diabetes since last 12 years and Coronary Artery Disease for the last 2 years presented in King Abdullah Teaching Hospital with the complaints of Chest pain and breathlessness for the last 6 hours. Patient had an episode of vomiting. He was conscious and well oriented. Overall health state was weak and meagre. Dept of Medicine Frontier Medical and Dental College
  3. 3. Dept of Medicine Frontier Medical and Dental College
  4. 4. Dept of Medicine Frontier Medical and Dental College
  5. 5. History of Patient • Name: Muhammad Shareef • Sex: Male • Age: 65 years • Marital Status: Married • Occupation: Retired Govt. servant • Address: Abbottabad • D.O.A: 20th February, 2015 • T.O.A: 9:30 am • M.O.A: OPD Dept of Medicine Frontier Medical and Dental College
  6. 6. Chief Complaints • Chest pain – 6 hrs • Shortness of Breath – 6 hrs • Vomiting - 5 hrs Dept of Medicine Frontier Medical and Dental College
  7. 7. History of Present illness • Known case of Diabetes - 12 yrs & Ischemic Heart Disease – 2 yrs • Chest pain started 6 hrs back • Sudden in onset • Retrosternal • Crushing in nature • Radiating to left arm, back and neck • Aggravated on exertion Dept of Medicine Frontier Medical and Dental College
  8. 8. History of Present illness • Shortness of breath – 6hrs • Sudden onset • present at rest • Vomiting – 5hrs • 2 episodes of vomiting • Vomitus was yellowish Dept of Medicine Frontier Medical and Dental College
  9. 9. History of Present illness Associated symptoms: • Moderate fever • Sweating • Dizziness • Patient was completely conscious • Palpitations Dept of Medicine Frontier Medical and Dental College
  10. 10. History of Present illness • Systemic Inquiry 1. General a. Reduced apetite b. Sleep disturbed c. Weakness 2. Respiration Cough, wheezing and hemoptysis not present Dept of Medicine Frontier Medical and Dental College
  11. 11. History of Present illness • Alimentary system: Nausea & Vomiting present • Urinary system: No significant history Dept of Medicine Frontier Medical and Dental College
  12. 12. History of Past illness • Past Medical History – Diabetes : 12 yrs – IHD : 2 yrs – HTN : Positive – TB : Negative – Asthma : Negative • Past Surgical History No significant past surgical history Dept of Medicine Frontier Medical and Dental College
  13. 13. Family History • Positive for IHD, HTN and DM • 2 brothers died of MI Dept of Medicine Frontier Medical and Dental College
  14. 14. Drug & treatment History • Patient was taking anti diabetics and anti hypertensive drugs • Drug compliance was poor • No other significant drug history Dept of Medicine Frontier Medical and Dental College
  15. 15. Personal History • Chronic Smoker • No history of drinking • Sedentary lifestyle Dept of Medicine Frontier Medical and Dental College
  16. 16. Socio-economic History • Satisfactory Dept of Medicine Frontier Medical and Dental College
  17. 17. History based Differential Diagnosis • Acute Myocardial Infarction • Unstable Angina • Pleurisy • Pericarditis • Pneumothorax • Pulmonary embolism • Reflex Esophagitis Dept of Medicine Frontier Medical and Dental College
  18. 18. General Physical Examination Patients general appearance • Pale and anxious Dept of Medicine Frontier Medical and Dental College
  19. 19. General Physical Examination • Vitals – B.P: 160/90mmHg in lying position – Pulse: 115 b/m, regular, tachycardia – Temp: 101 F – Resp: 30/m Dept of Medicine Frontier Medical and Dental College
  20. 20. General Physical Examination • No Clubbing, pallor, splinter hemorrhages koilonychias or leconichia • Mild tobacco staining observed • Xanthomas present on extensor surface of hands • Carotid pulse: thin • JVP: Not raised • Eyes: Anemia not present Dept of Medicine Frontier Medical and Dental College
  21. 21. General Physical Examination • Jaundice not present • Dental hygiene good • Carotid briut not audible • No abnormality on fundoscopy • No abnormality seen on thyroid examination • Lymph nodes not palpable • Pedal and Sacral edema absent • No other significant findings Dept of Medicine Frontier Medical and Dental College
  22. 22. Systemic Examination 1. CVS Systemic Examination a. Inspection: • No Chest deformity • No sternotomy or any other surgical scar b. Palpation: • Apex beat: Lateralized from mid clavicular line at 6th intercoastal spacece due to LVH Dept of Medicine Frontier Medical and Dental College
  23. 23. General Physical Examination • Heave: well sustained (at apex) • No left parasternal lift c. Auscultation: Mitral, Tricuspid, Aortic, Pulmonary Dept of Medicine Frontier Medical and Dental College
  24. 24. General Physical Examination • S1- Normal (Apex) • S2- Audible (Left sternal edge) • No added sounds • No murmurs Dept of Medicine Frontier Medical and Dental College
  25. 25. General Physical Examination c. GIT: • Liver not palpable • Spleen not palpable • Ascites not present d. Respiration: • Chest clear • No tracheal shift • No remarkable findings Dept of Medicine Frontier Medical and Dental College
  26. 26. General Physical Examination e. CNS: No remarkable findings Dept of Medicine Frontier Medical and Dental College
  27. 27. Examination based Differential Diagnosis • Myocardial Infarction • Unstable Angina Dept of Medicine Frontier Medical and Dental College
  28. 28. Investigations - ECG Dept of Medicine Frontier Medical and Dental College
  29. 29. Investigations ECG: Done within 25 mins of patient arrival Findings: • Rate: 78.9 • Rhythm: Sinus Rhythm Dept of Medicine Frontier Medical and Dental College
  30. 30. Investigations Leads showing ECG Changes: • V1 to V6, AvL • Changes include: • ST Segment Elevation • Q wave development • Loss of R Wave • T wave inversion Dept of Medicine Frontier Medical and Dental College
  31. 31. Investigations • Left Axis deviation seen by thumb rule on Lead 1 and AvF (For inferior wall MI, changes are seen in: Leads 2, 3 and AvF) Dept of Medicine Frontier Medical and Dental College
  32. 32. Investigations  Cardiac biomarkers • Trop T raised • CK-MB raised Chest Xray • Cardiothoracic ratio increased showing LV Dilatation • Pulmonary edema not evident Dept of Medicine Frontier Medical and Dental College
  33. 33. Investigations – Xray Dept of Medicine Frontier Medical and Dental College
  34. 34. Investigations Other Blood Tests • ESR and CRP raised Echocardiography could not be done due to the non availablity of facility. Dept of Medicine Frontier Medical and Dental College
  35. 35. Investigations based Diagnosis Anterolateral ST Segment Elevation Myocardial Infarction with Left Axis Deviation Dept of Medicine Frontier Medical and Dental College
  36. 36. Management • Patient was immediately admitted in ICU. Within 10 mins, ECG was performed and based upon diagnosis, following treatment was given. • Oxygen + Cardiac rhythm monitoring Dept of Medicine Frontier Medical and Dental College
  37. 37. Management • Aspirin 300mg PO • (Therapy should be continued indefinitely if there are no side affects) • Clopidogrel 600mg PO followed by 150mg daily for 1 week and 75mg daily thereafter. • Streptokinase 1.5ml I.V in 100ml sol at 6ml/hr • Inj Morphine • Inj Metoclopromide I.V Stat Dept of Medicine Frontier Medical and Dental College
  38. 38. Late Management • Patient advised on the following: • Lifestyle Modification: • Lipid Lowering diet • Cessation of Smoking • Regular exercise Dept of Medicine Frontier Medical and Dental College
  39. 39. Late Management • Secondary Drug therapy: • Aspirin • B blocker • Ace Inhibitor/ARB • Statin • Additional therapy for DM and HTN Dept of Medicine Frontier Medical and Dental College
  40. 40. The patient was given Streptokinase (Thrombolysis) within 8 hours of his arrival. He is still in the ICU undergoing 24/7 observation and treatment. He was advised angiography due to the unavailability of the facility at the Hospital. We wish him a speedy recovery.  Dept of Medicine Frontier Medical and Dental College
  41. 41. What is MI ? • Detection of rise and/or fall of cardiac biomarker values (preferably cardiac troponin) with atleast one of the following: • Symptoms of Ischemia • Significant ST segment-T wave changes or new LBBB • Development of pathological Q waves • Imaging evidence of new loss of viable myocardium • Angiographic identification of Intra coronary thrombus Dept of Medicine Frontier Medical and Dental College
  42. 42. Types of MI On the basis of ECG, there are two main types of MI • STEMI (major coronary artery complete obstruction) • Non-STEMI (Complete occlusion of a minor vessel or partial occlusion of a major coronary vessel Dept of Medicine Frontier Medical and Dental College
  43. 43. Arterial Supply of the Heart Dept of Medicine Frontier Medical and Dental College
  44. 44. Arterial Supply of the Heart Dept of Medicine Frontier Medical and Dental College
  45. 45. Arterial Supply of the Heart There are two major arteries which supply the heart • Left coronary artery • Right coronary artery 1. Left Coronary Artery: It is further divided into two main branches:  LAD (I/V septum, Ant. Wall of LV and Apex)  LCx (Lateral, Posterior and Inferior Walls) Dept of Medicine Frontier Medical and Dental College
  46. 46. Arterial Supply of the Heart 2. Right Coronary Artery It supplies RA, RV and inferio-posterior part of LV Branches include:  PDA (supplies I/V septum inferior part) In 90% individuals PDA is a branch of RCA. (Right Dominant people) In 10% individuals PDA is a branch of LCA (Left Dominant) Dept of Medicine Frontier Medical and Dental College
  47. 47. Arterial Supply of SA & AV Node • SA Node: RCA in 60% individuals • AV Node: RCA in 90% individuals Clinical Significance: • Proximal RCA occlusion may result in Sinus Bradycardia and may also cause AV Nodal block • Abrupt occlusion of RCA may lead to infarction of inferior part of LV Dept of Medicine Frontier Medical and Dental College
  48. 48. Conducting system of Heart Dept of Medicine Frontier Medical and Dental College
  49. 49. Nerve Supply of Heart • Adrenergic Nerves from the Cervical Sympathetic chain supply atria and ventricles • Parasympathetic: Vagus nerve Dept of Medicine Frontier Medical and Dental College
  50. 50. Pathophysiology of MI Atheromatous plaque formation Interplaque haemorrhages Exposure of Subendothelial collagen fibers Formation of micro thrombi Full blown thrombus vasospasm Dept of Medicine Frontier Medical and Dental College
  51. 51. Pathophysiology of MI Dept of Medicine Frontier Medical and Dental College
  52. 52. Pathophysiology of MI Dept of Medicine Frontier Medical and Dental College
  53. 53. Pathophysiology of MI • LCA Occlusion:  LAD occlusion (40-50) leads to Anterior wall infarction of LV Anterior portion of ventricular septum Apex  LCx Occlusion 15-20% Lateral wall of LV Dept of Medicine Frontier Medical and Dental College
  54. 54. Pathophysiology of MI  RCA Occlusion (30-40%) RCA occlusion leads to infarction of • Posterior wall of RV • Inferior wall of LV • Posterior 1/3rd of I/V septum Dept of Medicine Frontier Medical and Dental College
  55. 55. Clinical features  Symptoms: • Pain: Crushing, retrosternal chest pain radiating to back, left arm, neck or jaw • Anxiety and fear of impending death • Nausea and Vomiting • Breathlessness • Diaphoresis Dept of Medicine Frontier Medical and Dental College
  56. 56. Clinical features – Pain Areas Dept of Medicine Frontier Medical and Dental College
  57. 57. Clinical features • Signs  Sympathetic activation: - pallor - sweating - tachycardia  Vagal activation: -bradycardia Dept of Medicine Frontier Medical and Dental College
  58. 58. Clinical features  vomiting • Signs of impaired myocardial function:  Hypotention  Narrow pulse pressure  JVP may be raised Dept of Medicine Frontier Medical and Dental College
  59. 59. Clinical features  3rd heart sound  Quiet 1st heart sound  Diffuse apical impulse  Lung crepitations Dept of Medicine Frontier Medical and Dental College
  60. 60. Clinical features • Signs of tissue damage  fever • Signs of complications e.g Mitral regurgitation, pericarditis etc Dept of Medicine Frontier Medical and Dental College
  61. 61. Clinical features • Silent MI  diabetic patients  Older individuals Dept of Medicine Frontier Medical and Dental College
  62. 62. Investigations • ECG • Cardiac biomarkers • Chest X-Ray • Echocardiography • ESR & CRP • Angiography Dept of Medicine Frontier Medical and Dental College
  63. 63. Investigations • ECG It is central to confirming the diagnosis but may be difficult to interpret if there is bundle branch block or previous MI. so repeated ECGs are very important. Dept of Medicine Frontier Medical and Dental College
  64. 64. Investigations – Normal ECG Dept of Medicine Frontier Medical and Dental College
  65. 65. Investigations – Normal ECG Dept of Medicine Frontier Medical and Dental College
  66. 66. Investigations - ECG Earliest changes are seen in ST-segment 1. STEMI • ST-segment elevation • progressive loss of R wave . • Development of Q wave . • Resolution of ST-segment • T-wave inversion Dept of Medicine Frontier Medical and Dental College
  67. 67. Investigations - ECG 2. NSTEMI • St-segment depression • T-wave changes • Loss of R-wave • Absence of Q-wave Dept of Medicine Frontier Medical and Dental College
  68. 68. Investigations – ECG - STEMI Dept of Medicine Frontier Medical and Dental College
  69. 69. Investigations - ECG  Significance of chest leads  Antero-septal infarct v1 ,v2,v3,v4  Antero-lateral v4,v5,v6 and AVL and 1 Dept of Medicine Frontier Medical and Dental College
  70. 70. Investigations - ECG  Inferior infarction leads II , III and AvF  Posterior wall infarction doesn’t cause ST elevation or Q-waves in the standad leads but can be diagnosed by the reciprocal changes that is st depression and a tall R-wave and leads V1-V4. Dept of Medicine Frontier Medical and Dental College
  71. 71. Cardiac Biomarkers 1. Troponins 2. Creatinine kinases 3. LDH 4. AST 5. Myoglobins 6. Most specific are troponins and CK-MB Dept of Medicine Frontier Medical and Dental College
  72. 72. Cardiac Biomarkers 1. CK-MB Rises in 4-6 hours and peaks a 12 hours and falls to normal within 48-72 hours . It is very important. For diagnosis of recurrent MI’s. 2. Troponins: Trop-T and trop-I are gold standards for diagnosis of MI, Troponins rise in 4 to 6 hours and remains elevated for 2 weeks Dept of Medicine Frontier Medical and Dental College
  73. 73. Investigations- Chest Xray • Chest Xray to determine cardiomegaly and pulmonary edema Dept of Medicine Frontier Medical and Dental College
  74. 74. Investigations - Echocardiography • Useful for assessing ventricular function and determining complications Eg. Mural thrombus, cardiac rupture , VSD and pericardial effusion etc Dept of Medicine Frontier Medical and Dental College
  75. 75. Investigations - Other blood tests 1. ESR raised 2. Leucocytosis 3. CRP raised Dept of Medicine Frontier Medical and Dental College
  76. 76. Management Dept of Medicine Frontier Medical and Dental College
  77. 77. Management Dept of Medicine Frontier Medical and Dental College
  78. 78. Drugs used in treatment of MI 1. Analgesics - Opiates: Morphine Sulphate dimorphine 2. Anti-emetics: metoclopromide 3. Anti-thrombotic drugs a. Anti platelets: Aspirin - Clopidogrel - Ticagrelor - Gycoprotien 2b and 3a receptor antagonists: Abciximab Dept of Medicine Frontier Medical and Dental College
  79. 79. Drugs used in treatment of MI b. Anticoagulants : – LMW Heparin, HMW Heparin, pentasaccharide - fondaparinux – Warfarin Dept of Medicine Frontier Medical and Dental College
  80. 80. Drugs used in treatment of MI 4. Anti anginal drugs - Nitrates: GTN, isosorbide dinitrate - B blockers: metoprolol and atenolol 5. Dihydropyridine CCBs: - Nifedipine, amlodipine 6. Thrombolytics: - Alteplase, streptokinase, retiplase, tenecteplase Dept of Medicine Frontier Medical and Dental College
  81. 81. Invasive modalities used in the treatment of MI • PCI (Percutaneous Intervention) • CABG (Coronary Artery Bypass graft) Surgery Dept of Medicine Frontier Medical and Dental College
  82. 82. Late Management of MI Lifestyle modifications Diet Cessation of smoking Weight control Reguar exercise Dept of Medicine Frontier Medical and Dental College
  83. 83. Late Management of MI- Sec prevention • Anti platelet therapy • B blockers • Ace inhibitors • Statins • Additional therapy for diabetes and HTN control • Mineralocorticoid receptor antagonist • Devices: Implantable Cardiac Defibrillators Dept of Medicine Frontier Medical and Dental College
  84. 84. Complications • Arrythmias • Bradycardia • Acute Circulatory failure • Pericarditis Dept of Medicine Frontier Medical and Dental College
  85. 85. Complications - Mechanical • Rupture of papillary muscle • Rupture of I/V septum • Rupture of ventricle which can lead to fatal cardiac temponade • Embolism • Impaired ventricular function, remodeling and ventricular aneurysm Dept of Medicine Frontier Medical and Dental College
  86. 86. Prognosis • If medical care is not provided, death occurs in almost 1/4th of the cases. Half of the death occurs within 24nhours of the onset of symptoms and about 40% of all affected patients die within the first month. • Patients who reach the hospital and survive have much better prognosis with a 28 day survival of more than 85%. The prognosis of anterior infarcts is worse as compared to inferior infarcts. Dept of Medicine Frontier Medical and Dental College
  87. 87. Prognosis OF THOSE WHO SURVIVE AN ACUTE ATTACK, MORE THAN 80% LIVE FOR A FURTHER YEAR. ABOUT 75% FOR 5 YEARS. 50% FOR 10 YEARS & 25% FOR 20 YEARS. Dept of Medicine Frontier Medical and Dental College
  88. 88. Thankyou everyone  Dept of Medicine Frontier Medical and Dental Collegev

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