医学传媒医学传媒iology-iology-英文教学英文教学3AMI13AMI1Definitionmyocardial necrosis because of sustaining myocardial ischemia.oIschemiaoSustaining2Present HistoryPain is the most commonly complaint, with following features:1.Persistent central chest pain which is present in about 2/3 of all cases. It is sometimes described as “intense pressure” Usually, the patient will tell you he is dying, or some uncomfortable sensation beyond description.9Present History2. Associated symptoms: such as dyspnea, shortness of breath, palpitation, dizziness, nausea, and diaphoresis. The sweat may be heavy or slight. It may wet the shirt, or just be on the forehead.10Present History3. Referred pain: The chest pain often radiated to the shoulder and/or arms (usually the left side), the neck, jaw or abdomen. Actually from the lower margin of the ears to the ilium.11Present History4. Painless infarction: 23 percent of AMI are painless. More frequently in patients with diabetes mellitus, or in the elderly. 12Past HistoryoIschemic strokeoPeripheral artery diseaseoHypertensionoCigaretteoDiabetes mellitusoDyslipidemia13Physical findings: oTemperature: elevation in range 3738, oArrhythmia: Tachyarrhythmia (anterior) or Bradyarrhythmia (inferior).oAuscultation: weakened S1 in apical area.14Laboratory findingsoNonspecific indexesoECGoCardiac enzymes15ECGoTransmural AMI: pathologic Q waves in infarction area, and S-T segment elevation.oNontransmural AMI: S-T segment depressed and T waves inversion in all leads except aVR. oclasscification: STEAMI and NSTEAMI16ECGDifferent AMI ,Different ECGECG demonstrates the infarction area. 17ECGLocation of infarction by ECGArea of infarctionLeads with abnormal Q waveInferior, , aVFLateral, aVL, V6AnteriorV1V4diffuse AnteriorV1V5/V6AnteroseptalV1, V2/V3Right ventricularV3R, V4R, V5RPosteriorV7V91819ECG specific showoST segment elevationoQ wave formationoT wave inversionomirror change20ECG dynamic Evolution ohyperacute: peaked T wave;0-1 hoursoacute: ST segment elevation, Qwave formation; several hours to 1-2daysosubacute: ST segment elevation recovery, T wave inversion; to 1-2weeksochronic: T wave inversion recovery; to 1-2 months21ECGHyperacute inferior myocardial infarction22ECGInferior and right ventricular myocardial infarction23Cardiac EnzymeGolden criterion of myocardial infarction24Cardiac EnzymeoThe quantity of the enzyme implies the area or mass of the infarction myocardium. 25Cardiac EnzymeEnzymeRise time(after onset)Peak time(after onset)DurationCK6hrs24hrs3-4daysCK-MB30mins,cant be releived by sublingual NTGoat least 2 of neared leads ST segment elevation or new onset CLBBBocardiac markers increasewith 2 of those 3,STEAMI can diagnose. 29DiagnosisA new definition of myocardial infarction:Typical increase in the concentration of serum cardiac troponins or CK-MB associated with at least one of the following:osymptoms of cardiac ischemiaorecent pathologic Q waves in the ECGoischemic ST segment changes in the ECGocoronary artery revascularization.30Differential diagnosisoAngina pectorisoPericarditisoAcute pulmonary embolismoAortic dissectionoAcute abdomen (peptic ulcer perforation, cholecystitis, pancreatitis)31AnginaAMIDuration30minsSevereLightSevereResponseWellBadPericardial rubNoYesFeverNoYesLeukocyte increaseNoYesESRNoYescardiac enzymeNegativePositiveECGTransientEvolution32Complication oMyocardial ruptureoInterventricular septum perforation oDysfunction or rupture of papillary muscleoThrombosis and embolismoPostinfarction syndrome/Dresslers syndromeoVentricular aneurysmoPericarditisoVentricular remodelingoHeart failure and arrhythmia33Complication oMyocardial rupture position: septum; apex manifestation: BP HR lab: pericardial effusion (UCG) 34ComplicationoHeart failure dyskinesia of heart muscle mitral regurgitation (dysfunction of papillary muscles or fracture of mitral chordae tendineae) interventricular septum perforation 35Complication oHeart failure symptom (breathlessness, sweating) sign (Orthopnea, moist rales, gallop) lab (HR, hypoxemia)36ComplicationoKillip classification class ,no sign of pulmonary or venous congestion. class ,rales within the area less than half of the lung field class ,acute lung edema, rales within the area more than half of the lung field class , cardiac shock37ComplicationoArrhythmia any kind of arrhythmia can happen (VT, Vf, AVB) ventricular fibrillation is the most common form of fatal arrhythmia. tachycardia happens in anterior MI bradycardia happens in inferior MI 38Complication oPostinfarction syndrome continuous pain after MI(pericarditis) related to breath (pleuritis) fever leukocyte 39Complication oVentricular remodeling ventricular dilation expansion of the infarction,causing hemodynamic impairment/heart failure 40Treatment oOrdinary therapy: oxygen, restoAnalgesia oMedicineoReperfusion (thrombolysis, PCI, CABG)oComplication therapy41MedicineoAntiplatelet drugoAnticoagulantoStatinoNitrate oBeta-blockersoACEI(no CCB)42Reperfusion -thrombolysis ort-PA (recombined tissuetype plasminogen activator)o GUSTO protocol method:5000u heparin injection 15mg injection in bolus 50mg iv drip within 30mins 35mg iv drip within 60mins continuous heparin at least 48h43Reperfusion -thrombolysisoIndication : onset within 6 hours, at least 180/110 mmHg) active peptic ulcer tendency of bleeding accompanied by treatment of Warfarin45Reperfusion -thrombolysisoContraindication: pregnancy recent trauma or surgery aortic dissection acute pericarditis46Reperfusion-emergency PCIoPCI (percutanous coronary intervention) oincludingPTCA(percutanous transluminal coronary angioplasty)Stenting 47Reperfusion-emergency PCIoIndication: onset within 12h STEAMI 48Reperfusion-emergency PCIoContraindication hypersensitive to the contrast agents (I) tendency of bleeding septisis renal failure49Selection from thrombolysis and PCI oTime is myocardium, time is life.oAs early as we can, do reperfusion.oDoor to needle time:30minoDoor to balloon time:90minoDoor to balloon time-Door to needle time60min, PCI prefer 50Selection from thrombolysis and PCIoOnsetthrombosisoOnset 6-12h, PCIthrombosis51Selection from PCI and thrombosisPCIthrombosisadvantageReperfusion better, less risk of bleeding Quickly, dont need term, more convenience, cheapdisadvantageContrast renal injury, expensive, need experienced term, slowlyReperfusion incompletely,More risk of bleeding52treatment- right ventricle infarctiono1/3 of inferior AMI with right ventricle AMIohemodynamic characteristics-failure of right ventricle1.low BP2.congestation of vein3.lung clear53treatment- right ventricle infarctionolarge volume infusion-keep BP0.5-1litre frist hour, 3-6litres frist day.ono use of diuretics and nitratesoattention of bradyarrhythmia54long-term treatmento2 targets: artery lesion and ventricle remodelingoartery lesion: antiplatelet,statins,risks controloventricle remodeling: ACEI,beta-blockerosometimes ICD for dangerous ventricular arrhythmia55oKey points are in red color.5657