1. Complications of Acute Myocardial Infarction Willis E. Godin, DO

2. Overview Recurrent Ischemia/Infarction Recurrent Ischemia/Infarction Congestive Heart Failure/LV Failure Congestive Heart Failure/LV Failure Cardiogenic Shock Cardiogenic Shock Interventricular Septal Rupture Interventricular Septal Rupture Free Wall Rupture Free Wall Rupture Acute Mitral Regurgitation Acute Mitral Regurgitation Right Ventricular Infarction Right Ventricular Infarction Arrhythmias Arrhythmias Pericardial Effusion and Pericarditis Pericardial Effusion and Pericarditis

3. Recurrent Ischemia and Infarction Incidence of postinfarction angina without reinfarction is 20-30% Incidence of postinfarction angina without reinfarction is 20-30% Reduced incidence with primary PTCA Reduced incidence with primary PTCA May be due to occlusion of an initially patent vessel, reocclusion of an initially recanalized vessel, or coronary spasm. May be due to occlusion of an initially patent vessel, reocclusion of an initially recanalized vessel, or coronary spasm.

4. Left Ventricular Failure THE single most important predictor of mortality after AMI THE single most important predictor of mortality after AMI Characterized by either systolic dysfunction alone or both systolic and diastolic dysfunction Characterized by either systolic dysfunction alone or both systolic and diastolic dysfunction Increased clinical manifestations as the extent of the injury to the LV increases Increased clinical manifestations as the extent of the injury to the LV increases Other predictors of development of symptomatic LV dysfunction include advanced age and diabetes Other predictors of development of symptomatic LV dysfunction include advanced age and diabetes Mortality increases with the severity of the hemodynamic deficit Mortality increases with the severity of the hemodynamic deficit

5. Left Ventricular Failure LV failure – Congestive Heart Failure LV failure – Congestive Heart Failure Characteristically develop hypoxemia due to pulmonary vascular engorgement Characteristically develop hypoxemia due to pulmonary vascular engorgement Managed most effectively first by reduction of ventricular preload and then, if possible, by lowering afterload Managed most effectively first by reduction of ventricular preload and then, if possible, by lowering afterload

6. Left Ventricular Failure Treatment: Treatment: –Diuretics –Nitroglycerin –Vasodilators –Digitalis –Beta-adrenoceptor agonists –Other positive inotropic agents

8. Cardiogenic Shock Most severe clinical expression of left ventricular failure Most severe clinical expression of left ventricular failure Occurs in up to 7% of patients with AMI Occurs in up to 7% of patients with AMI Low output state characterized by elevated ventricular filling pressures, low cardiac output, systemic hypotension, and evidence of vital organ hypoperfusion Low output state characterized by elevated ventricular filling pressures, low cardiac output, systemic hypotension, and evidence of vital organ hypoperfusion

9. Cardiogenic Shock At autopsy, more than 2/3 of patients with cardiogenic shock demonstrate stenosis of 75 percent or more of the luminal diameter of all 3 major coronary vessels and loss of about 40 percent of LV mass At autopsy, more than 2/3 of patients with cardiogenic shock demonstrate stenosis of 75 percent or more of the luminal diameter of all 3 major coronary vessels and loss of about 40 percent of LV mass

10. Cardiogenic Shock Medical Management Medical Management –Same as tx for LV failure –Intraaortic balloon counterpulsation –Revascularization

11. Interventricular Septal Rupture Occurs in 0.2 percent of patients with AMI Occurs in 0.2 percent of patients with AMI Clinical features associated with increased risk of rupture: Clinical features associated with increased risk of rupture: –Lack of development of collateral network –Advanced age –Hypertension –Anterior location of infarction –thombolysis Higher 30-day mortality (74%) compared to those patients who do not develop this complication (7%) Higher 30-day mortality (74%) compared to those patients who do not develop this complication (7%)

12. Interventricular Septal Rupture The size of the defect determines: The size of the defect determines: –The magnitude of the left-to-right shunt –Extent of hemodynamic deterioration –Likelihood of survival Associated with complete heart block, right bundle branch block, and atrial fibrillation in 20-30 percent of cases Associated with complete heart block, right bundle branch block, and atrial fibrillation in 20-30 percent of cases

13. Interventricular Septal Rupture Characterized by the appearance of a new harsh, loud holosystolic murmur Characterized by the appearance of a new harsh, loud holosystolic murmur Best heard at the lower left sternal border Best heard at the lower left sternal border Usually accompanied by a thrill Usually accompanied by a thrill Can be recognized by 2-D echocardiography Can be recognized by 2-D echocardiography Catheter placement of an umbrella-shaped device within the ruptured septum Catheter placement of an umbrella-shaped device within the ruptured septum

14. Free Wall Rupture Features that characterize free wall rupture: Features that characterize free wall rupture: –Elderly –HTN –More frequently occurs in left ventricle –Seldom occurs in atria –Usually involves the anterior or lateral walls –Usually associated with a relatively large transmural infarction involving atleast 20% of the left ventricle –It occurs between 1 day and 3 weeks, but most commonly 1 to 4 days after infarction –Most often occurs in patients without previous infarction

15. Free Wall Rupture Usually leads to hemopericardium and death from cardiac tamponade Usually leads to hemopericardium and death from cardiac tamponade Occasionally, rupture of the free wall of the ventricle occurs as the first clinical manifestation in patients with undetected or silent MI, and then it may be considered a form of “sudden cardiac death” Occasionally, rupture of the free wall of the ventricle occurs as the first clinical manifestation in patients with undetected or silent MI, and then it may be considered a form of “sudden cardiac death”

16. Free Wall Rupture The coarse of rupture can vary from catastrophic, with an acute tear leading to immediate death, to subacute, with nausea, hypotension, and pericardial type of discomfort The coarse of rupture can vary from catastrophic, with an acute tear leading to immediate death, to subacute, with nausea, hypotension, and pericardial type of discomfort Survival depends on the recognition of this complication, on hemodynamic stabilization of the patient, and most importantly, on prompt surgical repair Survival depends on the recognition of this complication, on hemodynamic stabilization of the patient, and most importantly, on prompt surgical repair

18. Pseudoaneurysm Incomplete rupture of the heart, with organizing thrombus and hematoma, together with pericardium, seal a rupture of the left ventricle Incomplete rupture of the heart, with organizing thrombus and hematoma, together with pericardium, seal a rupture of the left ventricle With time this area of organized thrombus and pericardium can become a pseudoaneurysm that maintains communication with the cavity of the left ventricle. With time this area of organized thrombus and pericardium can become a pseudoaneurysm that maintains communication with the cavity of the left ventricle.

19. Pseudoaneurysm Can become quite large, even equaling the true ventricular cavity in size, and they communicate with the LV cavity through a narrow neck Can become quite large, even equaling the true ventricular cavity in size, and they communicate with the LV cavity through a narrow neck Diagnosis: 2-D echocardiography and contrast angiography Diagnosis: 2-D echocardiography and contrast angiography

21. Acute Mitral Regurgitation Due to partial or total rupture of a papillary muscle Due to partial or total rupture of a papillary muscle Rare but often fatal complication of transmural MI Rare but often fatal complication of transmural MI Complete transection of a left ventricular papillary muscle is incompatible with life because the sudden massive mitral regurgitation that develops cannot be tolerated Complete transection of a left ventricular papillary muscle is incompatible with life because the sudden massive mitral regurgitation that develops cannot be tolerated Rupture of a portion of a papillary muscle resulting in severe mitral regurgitation is much more frequent and is not immediately fatal Rupture of a portion of a papillary muscle resulting in severe mitral regurgitation is much more frequent and is not immediately fatal

22. Acute Mitral Regurgitation Patients manifest a new holosystolic murmur and develop increasingly severe heart failure Patients manifest a new holosystolic murmur and develop increasingly severe heart failure The murmur may become softer or disappear as arterial pressure falls The murmur may become softer or disappear as arterial pressure falls Recognized by 2-D echocardiography with color flow Doppler Recognized by 2-D echocardiography with color flow Doppler

23. Right Ventricular Infarction Frequently accompanies inferior LV infarction or rarely occurs in isolated form Frequently accompanies inferior LV infarction or rarely occurs in isolated form Right-sided filling pressures are elevated, whereas left ventricular filling pressure is normal or only slighty raised Right-sided filling pressures are elevated, whereas left ventricular filling pressure is normal or only slighty raised Cardiac output is often markedly depressed Cardiac output is often markedly depressed

24. Right Ventricular Infarction Common among patients with inferior LV infarction Common among patients with inferior LV infarction Unexplained systemic arterial hypotension or diminished cardiac output or marked hypotension in response to small doses of nitroglycerine in patients with inferior infarction should lead to the prompt consideration of this diagnosis Unexplained systemic arterial hypotension or diminished cardiac output or marked hypotension in response to small doses of nitroglycerine in patients with inferior infarction should lead to the prompt consideration of this diagnosis

25. Right Ventricular Infarction Most patients with RV infarction have ST segment elevation in lead V4R (right precordial lead in V4 position) Most patients with RV infarction have ST segment elevation in lead V4R (right precordial lead in V4 position) 2-D echocardiography : abnormal wall motion of the right ventricle as well as right ventricular dilitation and depressed RV ejection fraction 2-D echocardiography : abnormal wall motion of the right ventricle as well as right ventricular dilitation and depressed RV ejection fraction

26. Right Ventricular Infarction Medications routinely prescribed for LV infarction may produce profound hypotension in patients with RV infarction (especially nitroglycerine) Medications routinely prescribed for LV infarction may produce profound hypotension in patients with RV infarction (especially nitroglycerine) Initial treatment of hypotension in patients with RV infarction include volume expansion Initial treatment of hypotension in patients with RV infarction include volume expansion

27. Arrhythmias Ventricular arrhythmias Ventricular arrhythmias –Ventricular Premature Beats –Accelerated Idioventricular Rhythm –Ventricular Tachycardia –Ventricular Fibrillation Bradyarrhythmias Bradyarrhythmias –Sinus Bradycardia

28. Arrhythmias Atrioventricular and Intraventricular Block Atrioventricular and Intraventricular Block –First-Degree AV block –Second-Degree AV Block (Mobitz I / II) –Third degree (Complete) AV block –Intraventricular Block –Asystole Supraventricular Tachyarrhythmias Supraventricular Tachyarrhythmias –Sinus Tachycardia –Atrial Premature Contractions –Atrial Flutter –Atrial Fibrillation –Paroxysmal Supraventricular Tachycardia

29. Ventricular Arrhythmias Ventricular Premature Beats (PVCs) Ventricular Premature Beats (PVCs) Commonly seen in patients with acute MI Commonly seen in patients with acute MI Usually pursue a conservative approach and do not routinely prescribe antiarrhythmic drugs but instead determine whether recurrent ischemia or electrolyte/metabolic disturbances are present Usually pursue a conservative approach and do not routinely prescribe antiarrhythmic drugs but instead determine whether recurrent ischemia or electrolyte/metabolic disturbances are present

30. Ventricular Arrhythmias Accelerated Idioventricular Rhythm Accelerated Idioventricular Rhythm Defined as a ventricular rhythm with a rate of 60- 125 beats/min Defined as a ventricular rhythm with a rate of 60- 125 beats/min Frequently called “slow v. tach” Frequently called “slow v. tach” Seen in up to 20% of patients with AMI Seen in up to 20% of patients with AMI Occurs frequently during the first 2 days Occurs frequently during the first 2 days Probably results from enhanced automaticity of the Purkinje fibers Probably results from enhanced automaticity of the Purkinje fibers Often observed shortly after successful reperfusion Often observed shortly after successful reperfusion

31. Ventricular Arrhythmias Ventricular Tachycardia Ventricular Tachycardia When continuous ECG recordings during the first 12 hours of AMI are analyzed, nonsustained paroxysms of VT may be seen in up to 67% of patients When continuous ECG recordings during the first 12 hours of AMI are analyzed, nonsustained paroxysms of VT may be seen in up to 67% of patients Hypokalemia and hypomagnesemia may increase the risk of developing VT Hypokalemia and hypomagnesemia may increase the risk of developing VT Treatment may include: lidocaine, procainamide, amiodarone Treatment may include: lidocaine, procainamide, amiodarone

32. Ventricular Arrhythmias Ventricular Fibrillation Ventricular Fibrillation Ventricular fibrillation occuring in association with marked LV failure or cardiogenic shock entails a poor prognosis, with an in-hospital mortality rate of 40-60% Ventricular fibrillation occuring in association with marked LV failure or cardiogenic shock entails a poor prognosis, with an in-hospital mortality rate of 40-60% Tx : defibrillator Tx : defibrillator Management : lidocaine, amiodarone, bretylium Management : lidocaine, amiodarone, bretylium

34. Bradyarrhythmias Sinus Bradycardia Sinus Bradycardia Common arrhythmia occuring during the early phases of AMI Common arrhythmia occuring during the early phases of AMI Particularly frequent in patients with inferior and posterior infarction Particularly frequent in patients with inferior and posterior infarction Isolated sinus bradycardia, unaccompanied by hypotension or ventricular ectopy, should be observed rather than treated initially Isolated sinus bradycardia, unaccompanied by hypotension or ventricular ectopy, should be observed rather than treated initially Atropine should be utilized if hypotension accompanies any degree of sinus bradycardia Atropine should be utilized if hypotension accompanies any degree of sinus bradycardia

35. Atrioventricular and Intraventricular Block First Degree AV Block First Degree AV Block Occurs in less than 15% of patients with AMI admitted to CCUs Occurs in less than 15% of patients with AMI admitted to CCUs Generally does not require specific treatment Generally does not require specific treatment (Digitalis, B-blockers, Calcium antagonists) (Digitalis, B-blockers, Calcium antagonists)

36. Atrioventricular and Intraventricular Block Second-Degree AV block Second-Degree AV block –Mobitz Type I or Wenckebach Usually transient and does not persist more than 72 hours after infarction Usually transient and does not persist more than 72 hours after infarction Rarely progresses to complete AV block Rarely progresses to complete AV block Do not appear to affect survival Do not appear to affect survival Caused by ischemia of the AV node Caused by ischemia of the AV node Specific therapy not required Specific therapy not required

37. Atrioventricular and Intraventricular Block Second Degree AV block Second Degree AV block –Mobitz Type II Rare conduction defect after AMI Rare conduction defect after AMI Often progresses suddenly to complete AV block Often progresses suddenly to complete AV block Treated with a temporary external or transvenous demand pacemaker Treated with a temporary external or transvenous demand pacemaker

38. Atrioventricular and Intraventricular Block Complete (Third Degree) AV block Complete (Third Degree) AV block Often develops gradually, progressing from first-degree or type II second-degree block Often develops gradually, progressing from first-degree or type II second-degree block Treat with temporary external or transvenous demand pacemaker Treat with temporary external or transvenous demand pacemaker

39. Atrioventricular and Intraventricular Block Intraventricular Block Intraventricular Block –Isolated fasicular blocks »LAFB »LPFB –Right bundle branch block –Bifasicular block

40. Supraventricular Tachyarrhythmias Sinus Tachycardia Sinus Tachycardia Typically associated with augmented sympathetic activity (anxiety, persistent pain, LV failure, hypovolemia, epinephrine, atropine, etc.) Typically associated with augmented sympathetic activity (anxiety, persistent pain, LV failure, hypovolemia, epinephrine, atropine, etc.) Beta-adrenoceptor blocking agents frequently utilized Beta-adrenoceptor blocking agents frequently utilized

41. Supraventricular Tachyarrhythmias Paroxysmal Supraventricular Tachycardia Paroxysmal Supraventricular Tachycardia Requires aggressive management because of the rapid ventricular rate Requires aggressive management because of the rapid ventricular rate Augmentation of vagal tone – manual carotid massage Augmentation of vagal tone – manual carotid massage Drug of choice – adenosine (in non-AMI patients) Drug of choice – adenosine (in non-AMI patients) Alternatives: IV verapamil, diltiazem, metoprolol Alternatives: IV verapamil, diltiazem, metoprolol

42. Supraventricular Tachyarrhythmias Atrial Flutter and Fibrillation Atrial Flutter and Fibrillation Atrial flutter – usually transient Atrial flutter – usually transient Atrial Fibrillation occurs in 10-20% of patients with AMI Atrial Fibrillation occurs in 10-20% of patients with AMI The increased ventricular rate and the loss of atrial contribution to LV filling result in a significant reduction in cardiac output The increased ventricular rate and the loss of atrial contribution to LV filling result in a significant reduction in cardiac output Atrial fibrillation in AMI is associated with increased mortality and stroke Atrial fibrillation in AMI is associated with increased mortality and stroke

43. Pericardial Effusion Generally detected by 2-D echocardiography Generally detected by 2-D echocardiography More common in patients with anterior MI and with larger infarcts and when congestive heart failure is present More common in patients with anterior MI and with larger infarcts and when congestive heart failure is present Majority do not cause hemodynamic compromise; when tamponade occurs, it is usually due to ventricular rupture or hemorrhagic pericarditis Majority do not cause hemodynamic compromise; when tamponade occurs, it is usually due to ventricular rupture or hemorrhagic pericarditis

44. Pericarditis When secondary to transmural MI, pericarditis may produce pain as early as the first day and as late as 6 weeks after MI When secondary to transmural MI, pericarditis may produce pain as early as the first day and as late as 6 weeks after MI Treatment of pericardial discomfort consists of aspirin at does as high as 650mg every 4- 6 hours. (corticosteroids should be avoided because they may interfere with myocardial scar formation) Treatment of pericardial discomfort consists of aspirin at does as high as 650mg every 4- 6 hours. (corticosteroids should be avoided because they may interfere with myocardial scar formation) Dressler Syndrome Dressler Syndrome

45. Dressler Syndrome Post-myocardial infarction syndrome Post-myocardial infarction syndrome Usually occurs 1 to 8 weeks after infarction Usually occurs 1 to 8 weeks after infarction Patients present with malaise, fever, pericardial discomfort, leukocytosis, elevated ESR,and a pericardial effusion Patients present with malaise, fever, pericardial discomfort, leukocytosis, elevated ESR,and a pericardial effusion Cause of this syndrome not clearly established (? Immunopathological process) Cause of this syndrome not clearly established (? Immunopathological process) Treatment : ASA 650mg Q4hrs Treatment : ASA 650mg Q4hrs

46. Summary Be aware of all the potential complications that can arise from myocardial infarction, diagnose these complications when they occur, and treat the patient appropriately in a timely manner to reduce morbidity and mortality. Be aware of all the potential complications that can arise from myocardial infarction, diagnose these complications when they occur, and treat the patient appropriately in a timely manner to reduce morbidity and mortality.