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Myocardial Infarction
Henry Yao
Intern, Royal Melbourne Hospital
Introduction
Stable angina
Acute coronary syndrome
STEMI
NSTEACS
NSTEMI
Unstable angina
Introduction
Introduction
History
All causes central crushing chest pain or tightness radiating
Examination
Usually no signs
Signs of precipitants (e.g. anaemia, infection,
thyrotoxicosis, arrhythmias), risk factors, other
atherosclerotic diseases (PVD, stroke), complications
(e.g. MR, CHF)
Investigations
Investigations
Investigations
Acute Management
Oxygen therapy
GTN ( sublingual tab)
Aspirin 300mg
IV morphine 2.5~5mg + IV metoclopramide 10mg
Hospital Management
STEMI
STEMI
Subsequent management (start during this hospital admission)
Statins, aspirin and clopidogrel, ACEI (or ARB), -blocker (if
CI then CCB)
Anticoagulation therapy to prevent thromboembolism (warfarin
for 6mos if large anterior MI, esp if echo show large
akinetic/dyskinetic area, aneurysm or mural thrombus)
Nitrates PRN
Cardiac rehabilitation
Antiplatelet post stent
Aspirin for life
Clopidogrel for at least 6wks for metal stent
Clopidogrel for at least 12mos for drug eluting stent
Drug eluting stent have lower early re-stenosis rate c.f. bare
metal stent however have a problem of late thrombosis
Trop of 0.1
UA and NSTEMI
Stabilize acute coronary lesion
Risk Stratification
Presentation
ST segment deviation 0.5mm
cardiac enzymes
Risk Stratification
Haemodynaic compromise
ECG changes
Arrhythmia
Renal failure
Troponin rise
Diabetes mellitus
Ongoing chest pain
Cardiac bypass anytime or PCI in last 6months
Having 1 of these high risk group
Stable Angina
Summary
MOAN
ECG, troponin, R/O DDx
Code AMI
Reduce time to PCI
QUESTIONS!?
Quiz 1 - Complications
Early (0~48h)
Quiz 2
Quiz 3
PCI vs CABG
Advantage of PCI less invasive, less peri-operative
stay, morbidity and mortality
Advantage of CABG higher chance of
revascularization
PCI over CABG single or double vessel disease,
inability to tolerate surgery
CABG over PCI triple vessel disease or left main
disease, diabetes mellitus, failed PCI