1. MYOCARDIAL INFARCTION

2. CASE 1 Mr. A: 38 years old He smokes 1 pack of cigarettes per day He has no other past medical history 8 hours ago, he gets sharp central chest pain that is worse with inspiration. It has not yet resolved. He feels short of breath

3. CASE 2 Mr. D: 50 years old He also smokes 1 pack of cigarettes per day His past medical history includes hypertension and diabetes While he was working on the farm, he develops dull central chest pain that radiates to his neck With rest, the pain went away after about 5 minutes He also has shortness of breath

4. WHICH PATIENT IS HAVING AN MI? WHY?

5. HISTORY Pain Location Exertional Other symptoms: Shortness of breath Nausea Sweaty Risk Factors Family history Diabetes Hypertension Smoking Hyperlipidemia Previous MI or stroke

6. PHYSICAL EXAM Vital signs BP HR O2 saturation Cardiac exam S3 or S4 may be present Murmur of mitral regurgitation May have heart failure on cardiac and respiratory exam

7. ECG: ST ELEVATION MI

8. ECG

9. ECG: NON ST ELEVATION MI

10. ECG

11. STEMI VERSUS NSTEMI

12. MANAGEMENT: CASE When you examine Mr. D, he can talk to you BP 110/70 HR 100 O2 93% on room air He has normal heart sounds, no murmur, but has S4 Lungs are clear ECG shows ST depression and T wave inversion in V2- V6. What do you want to do next?

13. MANAGEMENT First, ABC’s! If you have cardiac monitor, put him on it IV access Oxygen What medications do you want to give him? For his pain? To prevent further thrombosis (antithrombotics)? To prevent arrythmia? To treat other cardiac risk factors?

14. MEDICATIONS: PAIN Nitrates Vasodilation of coronary arteries Decrease preload (venous vasodilation) Decrease afterload (arterial vasodilation) Be careful of hypotension (aortic stenosis, right ventricular MI) Morphine Avoid NSAIDS if you can

15. MEDICATIONS: ANTITHROMBOTIC Aspirin 162-325mg Po chewed x 1 then 75mg-100mg daily Patient needs to take indefinitely Decreases mortality Give as soon as you suspect an MI Consider clopidogrel 300mg PO x 1 then 75mg daily for 1-12 months Small additional benefit

16. MEDICATIONS: ANTICOAGULANTS Heparin Decreases risk of death and re-infarction If using unfractionated heparin IV, monitor PTT Duration is at least 48 hours

17. MEDICATIONS: PREVENTING ARRYTHMIA Beta blockers (eg. Atenolol, propranolol, metoprolol) Decreases mortality and ventricular arrythmias Start within 24 hours Contraindications Acute heart failure Heart block Asthma Hypotension No role for antiarrythmics such as lidocaine or digoxin No role for calcium channel blockers

18. MEDICATIONS ACE inhibitors (ramipril, enalopril) Especially beneficial in those with heart failure Start within 24 hours Prevents left ventricular remodelling

19. REPERFUSION 2 options A) Fibrinolytics If symptoms started less than 24 hours ago Contraindications: Uncontrolled hypertension, stroke in last 3 months, previous intracranial hemorrhage For STEMI patients only B) Percutaneous coronary intervention (PCI) If symptoms started less than 12 hours ago If the “door to balloon” time can be less than 90 minutes For STEMI patients. Can consider for NSTEMI patients

20. REPERFUSION Which NSTEMI patients should you think about sending for reperfusion? Chest pain and ischemia not responding to medications Unstable patients Arrythmias Heart failure

21. COMPLICATIONS Heart failure Bradycardia from AV (conduction) block Arrythmia Non sustained ventricular tachycardia (VT) Sustained VT and ventricular fibrillation New mitral regurgitation Ventricular wall rupture Cardiogenic shock