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)

for more information management-of-acute-myocardial-infarction-ami

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.

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.