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TEXTBOOK OF CORONARY THROMBOSIS. AND THROMBOLYSIS. Developments in Cardiovascular Medicine. garcaneapuzzra.mler. H. Suga and.
Table of contents

This frequently coincides with an inferior wall MI due to the shared blood supply.

Coronary Heart Disease, a Conversation with Dr. Harrington

Recall that a new left bundle branch block can indicate an acute MI, commonly of the left main coronary artery or proximal left anterior descending. The typical pattern with LVH includes deviation of the ST segment in the opposite direction of the QRS complex, or discordance, along with a typical T wave inversion pattern. Early repolarization Early repolarization is a common finding in young, healthy individuals.

It appears as mild ST segment elevation that can be diffuse but more prominent in the precordial leads. The persistent ST segment elevation is in lead V1 and V2 with an anterior or apical aneurysm. Revascularization can be performed by either primary PCI, fibrinolytic therapy thrombolytic therapy or surgically.

Primary PCI is preferred if available within a reasonable time-frame — that is, a door-to-balloon time of less than 90 minutes. The decision regarding primary PCI vs. However, smaller hospitals or those located in rural areas may not; those facilities frequently have capabilities to quickly transfer patients experiencing STEMI to a primary PCI facility.

When there is no primary PCI available, and transfer to a primary PCI facility is not able to be done in a timely fashion — that is, transfer in less than 60 minutes — fibrinolytic therapy is indicated. There are no situations in which fibrinolytic therapy is preferred over primary PCI, unless the patient refuses invasive procedures.

Fibrinolytic therapy works best when symptom onset is less than 3 hours, as fresh thrombus lysis is more readily treated than more organized, subacute thrombus.

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If symptoms have been present for more than 3 hours, then primary PCI is preferred. The best outcomes occur when primary PCI is performed with a door-to-balloon time of less than 90 minutes and when symptoms onset was less than 12 hours. Fibrinolytic therapy must be instituted within 24 hours of symptom onset.

After this time frame, fibrinolytic therapy is contraindicated and likely to be ineffective. Note that fibrinolytic therapy is always given simultaneously with anticoagulation using unfractionated heparin or low molecular weight heparin, as discussed under Anticoagulation in Medical Therapy. When the decision is made to treat a patient with STEMI with fibrinolytic therapy because primary PCI is not available in a timely fashion, contraindications must be considered.

Suspected aortic dissection, active bleeding excluding menses or a bleeding diathesis are contraindications to fibrinolytic therapy. Facilitated PCI refers to using fibrinolytic therapy to stabilize the patient while transport to a primary PCI facility is being arranged. This strategy receives a class IIb indication for high-risk patients with a low bleeding risk when primary PCI is not readily available. This is indicated after fibrinolytic therapy when cardiogenic shock or severe congestive HF develops Killip Class III , or when electrical instability ventricular tachycardia or fibrillation or persistent ischemic symptoms are present.

Coronary artery bypass grafting as a means of coronary revascularization during STEMI is indicated in the following situations:.


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CABG is not indicated when there is a small area of myocardium in jeopardy and the patient is stable. Medical therapy upon hospital discharge may include angiotensin converting enzyme inhibitors , angiotensin receptor blockers, aldosterone antagonists and HMG-CoA reductase inhibitors. Once STEMI is diagnosed, aspirin should be chewed at a dose of mg to mg immediately, unless a contraindication exists.

Cardiovascular Thrombus

Lifelong therapy using 75 mg to mg daily should follow upon hospital discharge. P2Y receptor antagonists clopidogrel, prasugrel, ticagrelor, ticlopidine are indicated in all STEMI cases unless surgery is needed. Clopidogrel can also be used as an adjunct to fibrinolytic therapy in patients who are intolerant to aspirin. If coronary artery bypass grafting is required, these agents should not be used; the drugs must be discontinued for 5 to 7 days prior to CABG, unless urgent and the risk for bleeding is less than the benefit of revascularization. Regardless of the type of stent used during PCI, it is preferred that thienopyridines be continued for 12 months if possible.

ESC/EACTS Guidelines on Myocardial Revascularization

Prasugrel is not recommended in a patient with a prior history of stroke or transient ischemic attack, or TIA. Ticlopidine is rarely used due to risk for thrombocytopenia and thrombotic thrombocytopenic purpura, or TTP. These drugs include abciximab, eptifibatide and tirofiban. Any of these agents may be used in addition to aspirin, a thienopyridine and anticoagulation except with bivalirudin at the time of PCI in high-risk patients with STEMI.

Either unfractionated heparin, low molecular weight heparin enoxaparin or fondaparinux or bivalirudin can be used; unfractionated heparin would be given for 48 hours total and low molecular weight heparin for 8 days or until hospital discharge. Nitrates are helpful to treat angina symptoms, hypertension and HF during STEMI; however, no clinical data exists to show a mortality benefit, and thus their use is individualized.

The use of nitrates should not preclude using drugs that do show a mortality benefit. Sublingual nitroglycerine tablets administered every 3 to 5 minutes, with a maximum dose of three tablets, can be given to relieve angina; should angina persist, intravenous nitroglycerine can be considered. Hypotension, or right ventricular infarction, is a contraindication to the use of nitrates.

Phosphodiesterase inhibitors sildenafil, vardenafil, tadalafil — used to treat erectile dysfunction — enhance nitric oxide production and can cause potentially fatal hypotension when used in combination with nitrates. These agents should not be used together within 24 hours sildenafil or 48 hours vardenafil, tadalafil due to this interaction. Morphine is effective in relieving anginal chest pains and the sensation of dyspnea when pulmonary edema is present.

There are also some beneficial hemodynamic effects including arterial vasodilation. Otherwise, oral beta-blocker therapy is given in the acute setting.


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  7. It is important to refrain from giving beta-blockers if there are signs of cardiogenic shock, such as hypotension or pulmonary edema on chest X-ray. Long-term lifetime therapy has been shown to reduce MI incidence and improve mortality. Caution must be used in the acute setting to avoid hypotension, which can worsen myocardial ischemia.

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    When LV function returns to normal and the patient does not have diabetes, the benefits are less clear. ARBs are generally given only if ACE inhibitors cannot be tolerated due to cough or other side effects. A class effect is likely present; therefore, spironolactone is frequently used instead of eplerenone due to cost concerns, although there is no direct data to support this practice. The nondihydropyridine calcium channel blockers diltiazem and verapamil can be used when there is a contraindication to beta-blockers, such as in asthma, and no HF or significant LV systolic dysfunction are present.

    Sublingual nifedipine is contraindicated due to a reflexive increase in the sympathetic nervous system, which can be harmful. There are quite a few mechanical and nonmechanical complications of STEMI, many of which are life-threatening. This results in end-organ hypoperfusion and potentially multi-system organ failure and can be fatal. Most commonly, the apex of the heart is involved; however, the inferior wall can form an aneurysm as well. There are four main concerns in patients with LV aneurysm. The most common cause of pre-hospital death during STEMI is ventricular fibrillation; the widespread availability of automated external defibrillators, or AEDs, has been of benefit in this situation.

    Ventricular tachycardia also commonly occurs as well during and after STEMI and can be life-threatening. This is a benign, hemodynamically stable rhythm, and no treatment is necessary. Below is one ECG example. Note the AV dissociation in the rhythm strip in lead V1 at the bottom; this is diagnostic for VT in the setting of a wide QRS complex tachycardia, but not always seen. Rapid control of heart rates is crucial to limit the extent of ischemia.

    Recall that oxygen demand increases as heart rate increases. Emergent cardioversion and amiodarone therapy are frequently needed in the setting of atrial fibrillation and STEMI. When infarction of the interventricular septum occurs, this area can thin with the remodeling process and, on occasion, a complete defect between the right and left ventricles can develop. This results in left-to-right shunting of blood and can be life-threatening when acute.


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    8. A holosystolic murmur at the left lower sternal border occurs. The ventricles are good at adapting to hemodynamic stress when gradually introduced, as in worsening aortic regurgitation; however, when acute, ventricular failure and shock occurs — as is present with acute VSD formation. Emergency surgical repair is warranted in this setting. Acute severe mitral regurgitation is a life-threatening disorder.