医学传媒iology-英文教学3AMI1课件

STSegmentElevatedAcuteMyocardialInfarctionBianBo,DongShaozhuangCardiovascularCenterTianjinMedicalUniversityGeneralHospital1Definitionmyocardialnecrosisbecauseofsustainingmyocardialischemia.IschemiaSustaining2AcutemyocardialinfarctionIschemia:Narrowingisthepredominantreasonforischemia.Sometimesischemiaiscausedbycoronaryspasm.3AcutemyocardialinfarctionAMIisalife-threateningmedicalemergencywhichdemandsimmediateactivationoftheemergencymedicalservices.Immediatetransportbyambulancetoahospitalwhereadvancedcardiaclifesupport(ACLS)isavailable.Themoretimethatpassesbeforemedicalattentionissought,themoreseverethepermanentheartdamageislikelytobe,andthelesslikelysurvivalwillbe.5pathologyMyocardiumchange

coronaryocclusion

20mimmyocardiumpathologicchanges

1-12hmyocardiumnecrosis

1-2winfarctedareafibrosis

6-8wscarformation

67PresentHistoryPainisthemostcommonlycomplaint,withfollowingfeatures:Persistentcentralchestpainwhichispresentinabout2/3ofallcases.Itissometimesdescribedas“intensepressure”Usually,thepatientwilltellyouheisdying,orsomeuncomfortablesensationbeyonddescription.9PresentHistory2.Associatedsymptoms:suchasdyspnea,shortnessofbreath,palpitation,dizziness,nausea,anddiaphoresis.Thesweatmaybeheavyorslight.Itmaywettheshirt,orjustbeontheforehead.10PresentHistory3.Referredpain:Thechestpainoftenradiatedtotheshoulderand/orarms(usuallytheleftside),theneck,jaworabdomen.Actuallyfromthelowermarginoftheearstotheilium.11PastHistoryIschemicstrokePeripheralarterydiseaseHypertensionCigaretteDiabetesmellitusDyslipidemia13Physicalfindings:Temperature:elevationinrange37~38℃,Arrhythmia:Tachyarrhythmia(anterior)orBradyarrhythmia(inferior).Auscultation:weakenedS1inapicalarea.14LaboratoryfindingsNonspecificindexesECGCardiacenzymes15ECGDifferentAMI,DifferentECGECGdemonstratestheinfarctionarea.17ECGLocationofinfarctionbyECGAreaofinfarctionLeadswithabnormalQwaveInferiorⅡ,Ⅲ,aVFLateralⅠ,aVL,V6AnteriorV1~V4diffuseAnteriorV1~V5/V6AnteroseptalV1,V2/V3RightventricularV3R,V4R,V5RPosteriorV7~V91819ECGdynamicEvolutionhyperacute:

peakedTwave;0-1hoursacute:

STsegmentelevation,

Qwaveformation;

severalhoursto1-2dayssubacute:

STsegmentelevationrecovery,

Twaveinversion;to1-2weekschronic:

Twaveinversion

recovery;

to1-2months21ECGHyperacuteinferiormyocardialinfarction22ECGInferiorandrightventricularmyocardialinfarction23CardiacEnzymeThequantityoftheenzymeimpliestheareaormassoftheinfarctionmyocardium.25CardiacEnzymeEnzymeRisetime(afteronset)Peaktime(afteronset)DurationCK<6hrs24hrs3-4daysCK-MB<4hrs16-24hrs3-4daysTNT2~4hrs7~14days26Diagnosis1985WHOSTEAMIDiagnosiscreteriatypicalischemiasymptom>30mins,can'tbereleivedbysublingualNTGatleast2ofnearedleadsSTsegmentelevationornewonsetCLBBBcardiacmarkersincreasewith2ofthose3,STEAMIcandiagnose.29DiagnosisAnewdefinitionofmyocardialinfarction:TypicalincreaseintheconcentrationofserumcardiactroponinsorCK-MBassociatedwithatleastoneofthefollowing:symptomsofcardiacischemiarecentpathologicQwavesintheECGischemicSTsegmentchangesintheECGcoronaryarteryrevascularization.30DifferentialdiagnosisAnginapectorisPericarditisAcutepulmonaryembolismAorticdissectionAcuteabdomen(pepticulcerperforation,cholecystitis,pancreatitis)31AnginaAMIDuration<30mins>30minsSevereLightSevereResponseWellBadPericardialrubNoYesFeverNoYesLeukocyteincreaseNoYesESRNoYescardiacenzymeNegativePositiveECGTransientEvolution32Complication

MyocardialruptureInterventricular

septumperforationDysfunctionorruptureofpapillarymuscleThrombosisandembolismPostinfarctionsyndrome/Dressler’ssyndromeVentricularaneurysmPericarditisVentricularremodelingHeartfailureandarrhythmia33ComplicationMyocardialruptureposition:septum;apexmanifestation:BPHRlab:pericardialeffusion(UCG)34ComplicationHeartfailuredyskinesiaofheartmusclemitralregurgitation(dysfunctionofpapillarymusclesorfractureofmitralchordaetendineae)

interventricular

septumperforation35ComplicationHeartfailuresymptom(breathlessness,sweating)sign(Orthopnea,moistrales,

gallop)lab(HR,hypoxemia)36ComplicationKillipclassificationclassⅠ,nosignofpulmonaryorvenouscongestion.classⅡ,raleswithinthearealessthanhalfofthelungfieldclassⅢ,acutelungedema,raleswithintheareamorethanhalfofthelungfieldclassⅣ,cardiacshock37ComplicationArrhythmiaanykindofarrhythmiacanhappen(VT,Vf,AVB)ventricularfibrillationisthemostcommonformoffatalarrhythmia.tachycardiahappensinanteriorMIbradycardiahappensininferiorMI38ComplicationPostinfarctionsyndromecontinuouspainafterMI(pericarditis)

relatedtobreath(pleuritis)feverleukocyte↑39ComplicationVentricularremodelingventriculardilationexpansionoftheinfarction,causinghemodynamicimpairment/heartfailure

40TreatmentOrdinarytherapy:oxygen,restAnalgesiaMedicineReperfusion(thrombolysis,PCI,CABG)Complicationtherapy41MedicineAntiplateletdrugAnticoagulantStatinNitrateBeta-blockersACEI(noCCB)42Reperfusion

-------thrombolysisrt-PA(recombinedtissuetypeplasminogenactivator)GUSTOprotocolmethod:5000uheparininjection15mginjectioninbolus50mgivdripwithin30mins35mgivdripwithin60minscontinuousheparinatleast48h’43Reperfusion

-------thrombolysisIndication:onsetwithin6hours,atleast<12hoursSTelevatedAMIornewonsetCLBBBwithischemicchestpain(necessary)44Reperfusion

-------thrombolysisContraindication:historyofcerebrovascularaccident(ischemicstrokewithinhalfayear;hemorrhagicstrokeanytimeinthepast)hypertension(>180/110mmHg)activepepticulcertendencyofbleedingaccompaniedbytreatmentofWarfarin45Reperfusion

-------thrombolysisContraindication:pregnancyrecenttraumaorsurgeryaorticdissectionacutepericarditis46Reperfusion---emergencyPCIPCI(percutanouscoronaryintervention)includingPTCA(percutanoustransluminalcoronaryangioplasty)Stenting47Reperfusion---emergencyPCIIndication:onsetwithin12hSTEAMI

48Reperfusion---emergencyPCIContraindicationhypersensitivetothecontrastagents(I)tendencyofbleedingseptisisrenalfailure49SelectionfromthrombolysisandPCITimeismyocardium,timeislife.Asearlyaswecan,doreperfusion.Doortoneedletime:<30minDoortoballoontime:<90minDoortoballoontime-Doortoneedletime<60min,PCIprefer

50SelectionfromthrombolysisandPCIOnset<3h,PCI=thrombolysisOnset3-6h,PCI>thrombosisOnset6-12h,PCI>>thrombosis51SelectionfromPCIandthrombosisPCIthrom