Myocardial Infarction

acute myocardial ischemia is caused by imbalance between myocardial oxygen supply and demand

• NSTEMI (non-st elevated MI)
• UA (unstable angina)

presence of a new ECG ST elevation in 2 or more leads

• clinical presentation
• ECG
• cardiac biomarkers
• rule out differential diagnosis

• aortic dissection
• peptic ulcer
• pericarditis

• chest pain/discomfort
• shortness of breath
• diaphoresis
• nausea/vomiting
• dizziness or syncope (fainting)
• fatigue/weakness

• CK-MB
• Troponin

they are released after cardiac cell injury and usuall appear within 3-6 hrs after myocardial damage

at least 3 times in 24 hrs (q8h)

CK-MB

7-14 days

predicts 30 day mortality after a MI

• control chest pain and assoc sx
• restore blood flow and min infarct size
• rule out differential dx
• prevent complications

• ventricular remodeling
• ventricular arrhythmias
• HF
• recurrent ischemia
• re-infarction
• cardiogenic shock
• stroke secondary to LV thrombus embolization

• venodilation (preload) and arterial vasodilation
• reduces myocardial O2 demand
• promotes coronary blood flow

• sublingual (0.4mg)
• topical (0.5-2inch)
• intravenous gtts (5-10mcg/min)

in STEMI if there is persistent ischemia, CHF, HTN

• hypotension
• flushing and HA
• reflex tachycardia/bradycardia
• tolerance to nitrate therapy

• sit down and put SL NTG under the tongue
• watch out for above SE
• store the tablet in the original container
• call 9-1-1 if pain is not relieved in 5 min

ISIS-2 study

• know hypersensitivity
• active bleeding
• severe bleeding risk

• O2 therapy should be continued beyond the first 6 hours in STEMI pts with:
• 1. oxygen desaturation
• 2. overt pulmonary congestion

caution with COPD and CO2

used for its analgesic and venodilatory effects

decrease HR, contractility, and BP

• 1. should be initiated within first 24 hrs in pts without any contraindications
• 2. should be used during and after any pt with STEMI and with no contraindications to their use
• 3. pts with initial contraindications to the use of B-blockers in the first 24 hours after STEMI should be reevaluated to determine their subsequent eligibility

25-50 to 200mg/day

6.25mg PO BID to 25mg PO BID

1. IND only in pts who are hypertensive or have ongoing ischemia and with no contraindications to their use

5mg q5min x 3 as tolerated

5mg q5min x 2

• sign of acute decompensated HF
• low output state
• increased risk of cardiogenic shock
• second or third degree heart block
• active asthma/ reactive airway disease

to restore myocardial perfusion in the infarct artery