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Acute Management of

Myocardial Infarction
Henry Yao
Intern, Royal Melbourne Hospital

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

Introduction

Stable angina normal ECG, normal troponin


Unstable angina normal troponin
NSTEMI elevated troponin
STEMI elevated ST segment

Criteria for thrombolysis or PCI (i.e. STEMI)


>1mm elevation in 2 contiguous limb leads
>2mm elevation in 2 contiguous precordial leads
New onset LBBB

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

Examination

Usually no signs
Signs of precipitants (e.g. anaemia, infection,
thyrotoxicosis, arrhythmias), risk factors, other
atherosclerotic diseases (PVD, stroke), complications
(e.g. MR, CHF)

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

Investigations

FBE anaemia, infection


UECR, coagulation study ability to take contrast and
undergo PCI

FBG, lipid profile (within 24h) DM,


hypercholesterolaemia

CXR r/o aortic dissection, pneumonia, pneumothorax,


interstitial lung disease

Investigations

Note: Troponin vs CKMB


CKMB rise in 4hr, elevated for 72hr
Trop rise in 8hr, elevated for 5 days (trop I) and 10 days
(trop T)

If trop ve repeat in 8hr last serial trop done 8hr


after sx resolves

CKMB can be used to detect second infarcts

Acute Management

Oxygen therapy
GTN ( 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

Reperfuse ASAP (within 12hrs of onset of sx i.e.


before MI is complete):
Antiplatelet therapy (aspirin and clopidogrel
GPIIb/IIIa inhibitor)
Anticoagulation agent (unfractionated heparin or
LMWH)

Immediate PCI or fibrinolytic therapy


PCI has higher reperfusion rate and is better if pt
present > 1hr but thrombolysis is gold standard if pt
arrive within an hour

STEMI
Subsequent management (start during this hospital admission)
Statins, aspirin and clopidogrel, ACEI (or ARB), -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

Trop of 0.1

UA and NSTEMI
Stabilize acute coronary lesion

Anti-platelet (aspirin and clopidogrel GPIIb/IIIa inhibitor)


Anti-thrombin (UFH or LMWH)
Anti-ischaemia (-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), blocker (if CI then CCB)
Nitrates PRN
Cardiac rehabilitation

Risk Stratification

TIMI Score (Para Sea)


Historical

PHx known CAD (stenosis 50%)


Age>65
3 RFs for CAD
Aspirin use in past 7d

Presentation
ST segment deviation 0.5mm
cardiac enzymes

Recent (24hr) severe angina

Risk Stratification

Risk stratification of NSTEACS HEART DOC

Haemodynaic compromise
ECG changes
Arrhythmia
Renal failure
Troponin rise
Diabetes mellitus
Ongoing chest pain
Cardiac bypass anytime or PCI in last 6months
Having 1 of these high risk group

Stable Angina

Statins, aspirin (or clopidogrel), ACEI, -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

Summary

MOAN
ECG, troponin, R/O DDx
Code AMI
Reduce time to PCI

QUESTIONS!?

Quiz 1 - Complications
Early (0~48h)

Any arrhythmias worry about AF, VT, VF, CHB


LVF cardiogenic shock
Medium (2~7d)
Any arrhythmias worry about AF, VT, VF, CHB
LVF cardiogenic shock
Rupture of papillary muscle (MR), IV septum, LV wall acute
cardiac failure APO death
Late (>7d)
Any arrhythmias worry about AF, VT, VF, CHB
Cardiac failure
LV aneurysm mural thrombus thromboembolism
Dresslers syndrome (3~8wk) recurrent pericarditis following AMI
(Hence why blockers given initially prevents arrhythmia as well as
rupture of cardiac muscle)

Quiz 2

Contraindication for thrombolysis

Past allergic reaction, past streptokinase use


Past stroke haemorrhagic (ever), ischaemic (6mos)
Brain tumour/trauma
Recent bleeding or risk of bleeding e.g. GI
bleeding, liver disease
Recent surgery
Hypertension
Pregnancy

Quiz 3

PCI vs CABG
Advantage of PCI less invasive, less peri-operative
stay, morbidity and mortality
Advantage of CABG higher chance of
revascularization
PCI over CABG single or double vessel disease,
inability to tolerate surgery
CABG over PCI triple vessel disease or left main
disease, diabetes mellitus, failed PCI

Copyright The University of Melbourne 2009