Acute MI (2 out of 3 criteria)
1)30 minutes retrosternal pain - must R/O MI, PE, Aortic dissection
2)Cardiac enzymes elevated
3)ECG changes
Unstable Angina -Chest pain at rest - cardiac ischemia w/o ECG changes
MI Causes - Related to stenosis of coronary arteries
Thrombosis – must consider coagulopathy in post-acute phase
Cocaine (Present similar to infarction or ischemia – Benzodiazepam, Nitrates, ASA is 1st line – avoid Beta-blockers – unopposed alpha-agonst activity worsens vasospasm; try CCB & alpha-blockers)
Dilated pupils (inhibits catecholamine – sympathetic activity) and blood-crusted nose
Vasculitis
Vasospasm (Prinzmetal’s angina – CCB)
Coronary dissection
Aortic root dissection
Symptoms: Chest: Pressure, Dyspnea, Diaphoresis, Nausea/Vomitting;
Signs of Heart Failure 2o to MI: Pedal edema, CHF, Elevated JVP
70 yo diabetics or females – atypical MI presentations - Dyspnea, Pulmonary edema, Arrythmia
S3 - Severe systolic dysfunction – Dialated heart failure
S4 - Myocardiac noncompliance from ischemia - atrial contraction against stiff ventricle (V hypertrophy)
ECG Story of MI
Hyperacute T (Tall T is impending infarction – often hyperkalemia)
ST elevation
Q wave development + R wave shrinkage
ST back to normal (if stays persistently for a week - consider LV aneurysm)
T wave inversion
Normal T wave
STEMI - ST elevation 1mm in 2 contiguous leads or new LBBB
Anterior V2-4 LAD
Lateral I, aVL, V5, V6 LCX
Inferior II, III, aVF RCA
Septal aVR, V1, V2
Cardiac Enzymes
CK 4-8hr (normal in 48-72hrs)
Trop1 6hrs (normal in 7-10 days) - 6 hours apart
TropT 6hrs (normal in 10-14 days) - 6 hours apart
Treatment of MI – Acute Stabilization (MONAH – Chest pain protocol)
Morphine - pain
Oxygen – positive O2 into lungs
Nitates - increases coronary blood flow, dilates venous system
ASA - antiplatelets
Heparin - anticoagulant
Acute treatment (Breaking the clot)
TNK in first 12 hours
PCI in first 4.5 hours
