Myocardial Ischemia and Infarction

Myocardial Ischemia and Infarction is a topic covered in the Pocket ICU Management.

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First Things First (assess for & treat the following)

  • Is pt hemodynamically stable?
  • Is pt continuing to have ischemia symptoms?
  • Are high-risk features present (see below)?
  • Does ECG show ST segment elevation or LBBB?
  • Are there contraindications to thrombolytic therapy (if indicated)?
  • Clinical syndromes
    • Chronic stable angina: fixed & stable coronary stenosis w/ absence of ischemia at rest, w/ ischemia provoked by normal physical states that increase myocardial metabolic demand (eg, physical exertion, emotional stress, post-prandial)
    • Unstable angina: broad category of self-limited ischemia in the absence of myocardial damage, as defined by an absence of serum cardiac enzyme elevation
      • Coronary plaque rupture w/ accumulation of intracoronary platelets & formation of transiently obstructing thrombus
        • Angina at rest, may be nocturnal
        • May follow recent history of MI
        • Represents the highest-risk group of pts w/ unstable angina
      • Previously stable coronary stenosis that slowly worsens due to progressive narrowing
        • Restenosis in the months following angioplasty is most common cause.
        • Gradually worsening exertional angina
      • Fixed & stable coronary stenosis w/ ischemia provoked by abnormal physical states that increase myocardial metabolic demand (eg, anemia, fever, tachyarrhythmia, hypotension, hyperthyroidism, cocaine use)
        • Symptoms abate as underlying disease process is corrected.
      • Coronary vasospasm
    • MI: resulting in death of muscle tissue & abnormal elevation of serum cardiac enzymes
      • Non-ST-segment-elevation MI (NSTEMI)
        • Infarction w/out elevation of ST segment on ECG
        • May result from occlusive thrombus, coronary vasospasm or fixed stenosis in the face of overwhelming myocardial oxygen demand or low oxygen delivery (supply-demand mismatch)
      • ST-segment-elevation MI (STEMI)
        • Infarction w/ elevation of ST segment in the ECG leads localized to the region of infarcting myocardium
        • Persistent coronary occlusion results in significant myocardial necrosis.
    • Acute coronary syndrome: defined as spectrum of the above clinical syndromes that arise from coronary plaque rupture & intracoronary thrombus formation (unstable angina, NSTEMI, STEMI)

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Last updated: May 9, 2010