Lecture Notes from ACS lecture by Dr. W Franklin, TCH/BCM
ECG Changes w an MI:
-hyperacute T waves (seen in first few minutes
-1mm ST elevation in 2 contiguous leads
-Q wave formation
-T wave inversion
check for "reciprocal changes" of ST depression in the opposite leads
Localize it to the infarct related art
II, III, aVF --> Inf MI --> RCA
DDx of STEMI by ECG...
-if diffuse changes, c/s pericarditis- diffuse ST elevation, PR depression (espec at inf leads) w PR elevation at aVR
-c/s early repol if all J pts are elevated
-WPW
-deeply inverted T waves w CNS xx & apical CM...
-...
RV infarct- shock w clear lungs bc it's right sided failure, inr JVP, Kussmauls sign
-give volume to maint RV preload...
CK pks within hrs and normalizes by 2 days or so
Troponin pks later (2 days), and take up to a week to return to Nl...
Tx of MI
-Goal: door to balloon angioplasty within 90 minutes
-mortality increases the longer you wait...
-better to get to cath lab than give fibrinolytics bc latter has bleeding risks/not as effetive...
ACC/AHA Recs
Timing: ...
-c/s not going to cath lab if >3hrs of Sx or unsure if truly an MI .......
c/s thrombolytics if PCI not available
-Alteplase or Reteplase or Tenecteplase
Absolute: c/i xx - prior intracranial hemorrhage, structural or malig CNS xx, prior ischemic stroke in past __ months, aortic dissection, ________________
Relative: recent <2-4wks internal bleeding, pregnancy, pepticulcers, ....
STEMI Mgt
-serial ECG
-ASA 325mg
-b-blocker if no c/i xx
-heparin bolus, then drip
-sublingual nitroglycerrin then a drip id chest pain or incr BP
-activate cath lab
-get echo for fx
-c/s giving clopidogrel if pt def going to cath lab
if cv shock --> no b blocker
ACEI/ARB, aldost blockers, statins all help if given around the time of infarct..., ideally ACE w/in 24hrs
xx
-septal infarct--> IVS rupture (hear a VSD murmur)
-ant infarct--> rupture free wall
-MV/pap muscle infarct--> acute MR
Arrhythmias
-if EF <30%, then c/s ICD (reduces risk of death by half...)
-if EF bn 30-40%, then get a life-vest and see if EF improves over the next month
Unstable angina- similar sx w/o ST changes consistently on ECG
-may need tx w b-blocker or morphine but not need to go back to the cath lab...
-give ASA, anticoag - hep gtt or lovenox, nitrates for CP and htn...