Myocardial Infarction Flashcards
STEMI
Complete and persistent blockage of artery
> 20m symptoms + > 20m persistent ECG changes:
2 contiguous leads -
— V2-3 STE - >=2.5mm m < 40y/>=2mm m > 40y/ > =1.5mm f
— other leads STE >=1mm
- new LBBB
And troponin rise
NSTEMI
Partial or intermittent blockage of an artery
And troponin rise
Risk factors for MI
1) Male
2) Advancing age
3) Manual employment
4) Location - highest in Scotland, lowest in England (highest in NW, lowest in SE)
5) Obesity, smoking. HTN, physical inactivity, high cholesterol, DM, FH
Dressler’s syndrome
Pericarditis occurs in 4% of post-MI patients
2-4 weeks post MI - self-limiting febrile illness + pericardial or pleural pain
Advice post-MI
1) stop smoking inc. passive smoking
2) cardioprotective diet
3) cardiac rehab programme / home-based rehab (www.theheartmanual.com)
4) exercise - 20-30 minutes/day to point of slight breathlessness
5) weight loss if overweight
6) alcohol within limits (14 units/week spread evenly over at least 3 days)
Cardioprotective diet
1) Low refined sugar
2) Salt < 6g/day
3) Wholegrains
4) 4-5 portions of nuts and seeds/week (portion = 30g)
5) > 2 portions of fish/week
6) >5 portions of fruit and veg/day
7) Olive oil or rapeseed oil for spreads, dressings, cooking, baking rather than animal fats eg. butter
8) Fat intake should be < 30% of total energy intake and saturated fat < 7%
9) no evidence for omega-3 & supplemented food
Exercise advice post-MI
1) > 150 mins/week of moderate intensity aerobic exercise (slightly SOB) - brisk walking/cycling/stairs
2) On 2 days do muscle strengthening activities that work all major muscle groups
1 unit of alcohol
Half pint 3% beer
Small measure (25ml) of spirit
Standard measure (50ml) of sherry / port
Medications initiated by secondary care post-MI
1) ACEi
2) Dual antiplatelet therapy for 12m (aspirin + clopidogren/ticagrelor) and then continue aspirin indefinitely - ticagrelor or prasugel more widely used than clopidogrel
3) BB - atenolol 50-100mg OD for 12m **
4) statin
5) If symptoms/signs of HF and LV dysfunction - add aldosterone antagonist (eplerenone)** wihtin 3-14 days of MI, preferably after ACEI initiation
NSTEMI/unstable angina management based on 6 month mortality risk
1) 300mg Aspirin and continue 75mg OD indefinitely + antithrombin (fondaparinux or if immediate angio/high bleeding risk UFH)
2)GRACE score defines next steps
> 1.5% -
i) DAPT (ticagrelor 90mg BD) for 12 months - if high risk bleeding/DOAC - clopidogrel - if needed > 12m reduce dose of T to 60mg BD.
> 3% -
i) angiography within 72h
ii) DAPT Prasugrel 5mg OD (10mg if > 60kg and < 75y) OD (once PCI intended)/ticagrelor 90mg BD (60mg BD if used > 12m) - give clopidogrel of DOAC/high bleeding risk
3) Post MI meds - **ACEi / BB atenolol 12m / statin
**
4) If HF + LVD - eplerenone withihn 30-14 days of MI after ACEi
Driving post-MI
G1: does not need to tell DVLA, but should temporarily stop depending on type of MI and treatments
G2: stop for set period and inform DVLA
Sex post-MI
Can resume after 4 weeks, no increased risk of triggering further MI
> 6 months, can consider PDE5 inhibitor, unless on nitrates/nicorandil
Initial management of MI
Oxygen if SpO2 < 94%, monitor with oximeter
Aspirin 300mg
GTN
ECG
Emergency admission: current chest pain/pain in last 12h
Same day assessment: chest pain 12-72h ago
ECG + troponin before further action if chest pain > 72h ago
Management post PCI
Add prasugrel or ticagrelor to aspirin, stop second antiplatelet after 12m (may be less if high risk of bleeding)
Fibrinolysis
Repeat ECG at 60-90m - if STE –> angio +/- PCI
GIve UFH even if they have had fondaparinux
