Acute Myocardial Infarction Management REGIME FOR MANAGEMENT OF AMI

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REGIME FOR MANAGEMENT OF AMI

  • Twelve lead ECG is done.
  • Or If there is ST elevation more than 1 mm in any lead or 2 mm in V1′ V2 ,
  • In comparison, fibrinolytic therapy has largely not been effective in patients with a non-ST elevation MI (NSTEMI)
  • then reperfusion therapy is given with streptokinase, tPA, or APSAC by IV infusion or percutaneous coronary intervention. (PCI).
  • A potential method of shortening the in-hospital time to fibrinolysis is use of an ECG-based fibrinolytic predictive instrument (TPI)

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Morphine I analgesics

  • Aspirin + Clopidogrel – 2 tabs of 300 mg each to be chewed.
  • Low molecular weight heparin.
  • NTG infusion (nitroglycerine) GP IIb I IIIa antagonist.
  • Avoid steroids, NSAIDS, except aspirin.

Ischemic Cardiomyopathy 2

REGIME FOR MANAGEMENT OF AMI

 

Thrombolysis in Acute MI

  • tPA – tissue plasminogen activator. tPA is more effective than STK.
  • Streptokinase – 1.5 million units in 100 ml nor­mal saline IV is given in 60 minutes.
  • APSAC-Anisoylated plasminogen strepto-kinase activator complex – !V bolus 30 mg in 5 min­utes.
  • rPA-retiplase-recombinant tissue plasminogen activator

TIMI Grade —

  • Grade 0  — Complete occlusion.
  • Grade I — Some penetration of contrast material but no perfusion of distal coronary bed.
  • Grade II — Perfusion of entire infarct vessel – with delayed flow.
  • Grade III –Full perfusion of vessel with normal flow.

Aim of Thrombolysis is to achieve TIMI III flow

  • TIMI frame count – Number of frames for dye to flow from origin of vessel to target.
  • TIMI  myocardial perfusion grade – Rate of entry and exit of contrast dye from myocardium.

Benefits of thrombolytic therapy

  • Decreases mortality
  • Decreases infarct size Limits LV dysfunction
  • Decreases incidence of malignant ventricular arrh thmias.

Hibernating Myocardium

  • Is poorly contracting myocardium due to stenosed , infarct related artery, improves after reperfusion.

GP lIb / IlIa antagonist

  • A new regime is to give reduced dose ofthrombolytics plus IV Gp IIb I IIIa antagonist.

Contraindications of STK and other thrombo­Iytics

  • Cerebral haemorrhage
  • Cerebro vascular accidents in past one year
  • Hypertension – systolic blood pressure> 180 mmHg and diastolic blood pressure> 110 mmHg
  • Aortic dissection
  • Elderly.

 

Relative Contraindications

  • PT – INR more than 2
  • Recent surgery
  • Recent intervention
  • CPR of more than 10 minutes .
  • Bleeding diathesis
  • Pregnancy
  • Haemorrhagic diabetic retinopathy
  • Peptic ulcer
  • Severe hypertension
  • H/o of STK infusion in 5 days to 2 years.

 

Untoward effects of Streptokinase

  • Hypotension
  • Allergy
  • Haemorrhage_(haemorrhagic stroke in 0.5 to
  • 0.9%, specialy in older patients).

Oxygen

  • Check SP02 and give 02 inhalation 2 to 4 L/min for 12 hours. – –

 

Indications of Coronary Angiography in AMI

  • Persistent chest pain
  • ST elevation for more than 90 minutes
  • Recurrent chest pain
  • Recurrent ST elevation.
  • Revascularization is done as required by percutane­ous coronary intervention (PCI) or coronary artery bypass graft surgery.

Rescue Angioplasty

  • If coronary ischemia persists despite thrombolytic therapy then PCI  — angioplasty with or without stent is_required.
  • Primary percutaneous coronary intervention (PCI) is now preferred for most patients if it can be performed by an experienced operator with less than a 90 minute

Primary PCI

  • Angioplasty with or without stenting in first few hours of AMI is primary PCI.
  • It should only be done in cen­ters of excellence, experience, and only it can be done as fast as IV, STK.
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