Warning:
• The plasma troponin assay (emergency) has become the reference for diagnosis: the need for a laboratory equipped in town.
• Is now considered “myocardial infarction” any elevated plasma troponin.
• Is designated more broadly as “acute coronary syndrome” (ACS) all ischemic situation regarding atherosclerotic plaque rupture intracoronary with thrombus formation more or less occlusive.
• The SCA is described with or without ST segment elevation on ECG with or without troponin elevation.
• Evolution potentially very serious: heart attack, sudden death, recurrent ischemia.
• The therapeutic approach varies according to the initial presentation of the ECG and biology made urgently.
• Aspirin, clopidogrel (PLAVIX irreplaceable) and beta-blockers are the basic salaries.
Clinical (heart):
Typically wide retrosternal pain, bar, constrictive, overwhelming, with brachial irradiation and jaw, agonizing, with sweats, feeling of imminent death, prolonged and not nitrosensible.
common pitfalls: IDM lower abdominal form with epigastric pain and vomiting; pain reduced to radiation or little intense.
Electrocardiogram:
Typically one another: subendocardial ischemia (giant wave positive T) subepicardial lesion encompassing the T wave (convex STEMI up = wave Pardee) is reducing in case of reperfusion or after the 6th hour, ischemia injury subepicardial then (negativation T) with onset of Q wave transmural necrosis.
Direct signs appear in the infarct territory (with a mirror image in the opposite derivations) and correspond to a specific artery.
IVA: anterior.
CX: circumflex.
CD: right coronary.
VD: right ventricle.
You can see the atrial arrhythmias (atrial fibrillation) and ventricular (single or burst ESV).
Cardiac enzymes:
Allow a positive diagnosis in emergency: troponin and myoglobin.
Confirm the diagnosis retrospectively: CPKMB from the 3rd hour, AST (SGOT) and LDH later.
What to do in the patient’s home:
– Define the diagnosis (clinical + ECG); interest of a previous ECG.
– Allow the ECG connected ++.
– Eliminate spasm, lifted by 2 puffs of NATISPRAY [NTG], possibly renew.
– Call the ambulance, do not leave the patient:
– KARDEGIC [lysine acetylsalicylate] 160 mg per os or ASPEGIC [acetylsalicylate DL] 500 mg IV if vomiting.
– No intramuscular injection +++.
– Morphine Hydrochloride: 1/2 to 1 ampoule SC.
To the hospital:
ACS STEMI ST:
– Reperfusion in emergency:
1 / the home thrombolysis EMS is mainly used when one is not a quick (less than 1 hour) to a technical platform for coronary angiography and angioplasty, and in the absence of against indications;
2 / if not, coronary angiography is almost always done in the initial phase +++ for assessment of damage and reperfusion.
ACS without ST segment elevation:
– Aspirin: ASPEGIC 500 mg IV or orally.
– Clopidogrel: PLAVIX 4 cp loading dose.
– Heparin of low molecular weight LOVENOX 0.1 ml / 10kg / 12 hours.
– Beta-blockers: Tenormine 5 mg IV relayed by 100 mg orally every 6 hours.
– Nitrocompounds: RISORDAN 2 to 5 mg / hour; cons-indicated in cases of infringement of VD.
In case of troponin elevation, for angioplasty, use of GP2B3A antibody infusions.
All acute coronary syndrome with or without stent will require 12 months of combination therapy with anti-platelet aggregation PLAVIX (irreplaceable) 1 tab / day and KARDEGIC 75 mg / day.
The waning of ACS, angiotensin converting enzyme: very low initial dose followed by gradual dose escalation:
– IDM all comers: ZESTRIL 5 mg / day from the 24th hour
– IDM with signs of heart failure: from the 3rd day Triatec 2.5 mg 2 times a day.
Complications of infarction:
Cardiac arrest:
Most often a result of ventricular fibrillation: exceptionally effective sternal punch, especially external electric shock (EEC) 200 or 300 J immediately, even if no ECG available. Interest of a defibrillator available in the medical office …
external cardiac massage, mask ventilation before intubation.
Vagal reaction:
Usual in the lower IDM. Combines sweating, nausea, hypotension and sinus bradycardia sometimes BAV type II Luciani-Wenckebach.
Gives ATROPINE with 0.5 to 1 mg IVD and elevating the feet.
Left ventricular failure:
Linked either to the extent of necrosis or to a mechanical complication such acute mitral regurgitation by breaking / necrosis pillar (surgical emergency): echocardiography.
Its existence-against states or requires mandatory stop beta blockers, the introduction of diuretics (Lasix IV), the introduction of the IEC as soon as possible.
In case of cardiogenic shock (SBP <90mmHg), transfer to specialized center for attempted mechanical extreme emergency unblocking during a coronary angioplasty.
Right ventricular infarction:
Associated with lower IDM, give a picture of IVD with hypotension, normal lungs, ST segment elevation in V3R V4R (and D2D3VF), akinesia-RV dilation on echocardiography.
Against-indication nitro and diuretics instead require filling by macromolecules for pulmonary capillary pressure to 18 mmHg.
Arrhythmias and conduction:
– Ventricular: treat only if they are polymorphic, in bursts, with phenomena R / T (occurring on top of the T wave sinus complex): XYLOCARD IV.
– Ventricular tachycardia:
– Sternal punch
– EEC urgently if poorly tolerated TV, or after brief general anesthesia,
– Preventing relapses by XYLOCARD IV: 1 to 1.5 mg / kg bolus (5ml = 100mg), followed by 5% XYLOCARD infusion: 1.5 to 4 mg / min,
– Or by central venous CORDARONE 600 to 1200 mg / day.
– Idioventricular accelerated pace ( “Slow TV”) can announce reperfusion. No treatment.
– Atrial fibrillation :
– Effective anticoagulation,
– CORDARONE to loading dose,
– In the event of poor tolerance (angina, OAP, collapse), EEC.
– Block sinoatrial: If lower IDM, may require pacing (SEA).
– Atrioventricular block Mobitz type II and III: well tolerated in case of lower IDM, quickly resolutives with ATROPINE exceptionally probe SEA; poorly tolerated in an anterior MI, systematic SEA probe at the onset of a left bundle branch block, a BBD or BBD + + HBAg HBPG.
Pericarditis:
Especially in earlier necrosis: diagnosis on ECG and echocardiography.
Reduction or temporary cessation of anticoagulants, NSAIDs such INDOCID 150 mg / day or ASPEGIC 1 to 2g / day.
The post-infarction:
The BASIC as treatment for angina (B + A platelet êtabloquant ntigrégant + S + I tatin nhibiteur the renin-angiotensin system + C ontrol risk factors) and can be added in recent myocardial OMACOR [omega 3 fatty acids] 1 tablet per day, for an anti-arrhythmic effect.
– Fixed risk factors +++.
– Rehabilitation in specialized centers (inpatient or outpatient).
– Physical activity endurance.
– Support for the resumption of confidence (psychological care ++).
– KARDEGIC 75 mg / day and irreplaceable PLAVIX, 1 tab daily.
– IEC dose-escalation: ideally ideally COVERSYL [perindopril] up to 10 mg / day, Triatec [ramipril] up to 10 mg / day.
– Systematic Beta-blockers (except cons noted): their use improves long-term survival; SECTRAL 200 mg x 2 daily, 200 mg SELOKEN LP 1 a day.
– Isoptine 120 mg x 3 per day in the absence of heart failure if cons-indication to beta-blockers (the only calcium antagonist approved for this indication).
– Statin: pravastatin or simvastatin 40 mg / day or TAHOR [atorvastatin] or CRESTOR [rosuvastatin] systematically ++, although normal cholesterol ++. The goal is to get LDL cholesterol <1 g / l.
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