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 Table of Contents  
CLINICAL QUERIES
Year : 2016  |  Volume : 14  |  Issue : 4  |  Page : 82-83

Clinical questions: Responses to queries from readers: Myocardial Infarction


Professor, Department of Family Medicine, CMC, Vellore, India

Date of Web Publication22-Nov-2016

Correspondence Address:
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-4651.194452

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How to cite this article:
David KV. Clinical questions: Responses to queries from readers: Myocardial Infarction. Curr Med Issues 2016;14:82-3

How to cite this URL:
David KV. Clinical questions: Responses to queries from readers: Myocardial Infarction. Curr Med Issues [serial online] 2016 [cited 2019 Oct 19];14:82-3. Available from: http://www.cmijournal.org/text.asp?2016/14/4/82/194452

Question 1

What
are the latest recommendations for management of a patient with myocardial infarction which can be given at a remote center before referral to a cardiologist in a distant city?

Dr. Gayatri
R. Banerjee, Bargarh, Odisha.

Answer:


It would be helpful to know if the center has a facility for electrocardiogram (ECG). A diagnosis of acute myocardial infarction is made after appropriate history, focused physical examination, 12-lead ECG, and myocardial injury biomarkers.

The typical clinical presentation of acute coronary syndrome (ACS) includes retrosternal compressive pain of sudden onset radiating to left arm, jaw, or neck and may be intermittent or persistent. Atypical presentations include dyspepsia, stabbing type of chest pain, pleuritic chest pain, and dyspnea. Younger adults, women, and diabetic individuals may present with atypical presentations. [1] If ACS is suspected, an ECG should be taken and further management is started based on the ECG finding.


  Diagnosis Top


If the ECG shows ST elevation, the diagnosis of ST elevation myocardial infarction or (STEMI) is considered. If there is no ST elevation and myocardial injury biomarkers such as troponin T and creatine kinase-MB (CKMB) are elevated, then a diagnosis of non-STEMI is considered. If there are no ECG changes and levels of Troponin T and CKMB are within normal range, then the diagnosis is unstable angina. Each of these diagnoses has a different management.


  Management of Patients Suspected to have ST Elevation Myocardial Infarction Top


STEMI is diagnosed based on any one of the following criteria: [2]

  • Chest pain with >1 mm ST elevation in adjacent leads in the ECG
  • Appearance of new Q wave
  • New left bundle branch block.
If the patient can be shifted quickly to a referral center, then you need to give nitrates 10 mg, aspirin 300 mg, and clopidogrel 300 mg stat pain relief using morphine subcutaneously and transferred if possible with nasal oxygen. [1] Referral must be done if percutaneous coronary intervention (PCI) is available at the referral center within 2 h of transport. If not, fibrinolysis should be initiated in the same center [Figure 1]. [1]
Figure 1: Flowchart for management of ST-elevation myocardial infarction

Click here to view


Fibrinolysis can be initiated with intravenous streptokinase 1.5 million units in 100 ml saline infused over 60 min. The absolute contraindications to thrombolysis are if patient had major surgery within 20 days ago, was on warfarin, has a blood pressure >200/120 mmHg, had recent GI bleed, and a cerebrovascular accident within 3 months. [3]


  Complications after Fibrinolysis Top


The complications which the treating physician needs to be alert for are as follows:

  • Significant arrhythmia
  • Hypotension
  • Left ventricular failure.
On the second day of successful fibrinolysis, the patient needs to be started on angiotensin converting enzyme inhibitor, atorvastatin, cardioselective beta blockers, and aspirin 100 mg. If fibrinolysis is unsuccessful, then the patient will definitely need to be referred for PCI.


  Management of Patients Suspected to have ST Elevation Myocardial Infarction Top


The following comprise the essential management of NSTEMI:

  • Admit for bed rest
  • Continuous ECG monitoring if available
  • Aspirin 325 mg stat followed by 150 mg and clopidogrel 300 mg followed by 75 mg
  • ACE-Inhibitor, nitrates, beta blockers, and low-molecular-weight heparin (enoxaparin) at 1 mg/kg bid subcutaneously for 3-5 days.
Fibrinolysis should not be done for NSTEMI or unstable angina. At discharge, the patient needs to be evaluated with ECHO and stress testing for future revascularization. He/she also needs to be advised life style modification of diet, weight reduction, and moderate exercise.

Address for sending clinical queries: Dr. Tony Abraham Thomas, Continuing Medical Education (CME),

Christian Medical College, Vellore, Tamil Nadu, India.

E-Mail: tonyabthomas@gmail.com

 
  References Top

1.
Daga LC, Kaul U, Mansoor A. Approach to STEMI and NSTEMI. J Assoc Physicians India 2011;59 Suppl:19-25.  Back to cited text no. 1
    
2.
Campbell-Scherer DL, Green LA. ACC/AHA guideline update for the management of ST-segment elevation myocardial infarction. Am Fam Physician 2009;79:1080-6.  Back to cited text no. 2
    
3.
KCPPHC Clinical Guidelines. Available from: http://www.sites.google.com/site/kcpphc/home/clinical-guidelines. [Last accessed on 2016 Sep 25].  Back to cited text no. 3
    


    Figures

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