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文檔簡介

ACUTEMYOCARDIALINFARCTION〔AMI〕

DefinitionPrevalence

CauseSymptomsandsignsAuxiliaryexaminations

。Contents

DiagnosisThedifferentialdiagnosiscomplications

Therapy

。DefinitionDeathornecrosisofmyocardialcells.DefinitionFromananatomicormorphologicstandpoint----transmural----nontransmural.DefinitionFromECGfinding--STelevationSTEMI--non-STelevationNSTEMIPrevalenceTheWorldHealthOrganizationestimatedin2004,that12.2%ofworldwidedeathswerefromischemicheartdisease.Leadingcauseofdeathinhigh-ormiddle-incomecountries.

Secondonlyto

lowerrespiratoryinfectionsinlower-incomecountries.Worldwide,morethan3millionpeoplehaveSTEMIsand4millionhaveNSTEMIsayear.STEMIsoccurabouttwiceasofteninmenaswomen.Ingeneral，MIcanoccuratanyage，butitsincidentriseswithage.Approximately50%ofallMI’sin

theUSoccurinpeopleyoungerthan65yearsofage.MortalityThemortalityis50%in24hours.CauseCoronaryatherosclerosisFormationofthrombusObstructionofbloodflowMuscledeathincardiacmusclePlaquerupture

→adventitialipidcoreCholesterolnuclearthrombosis

Rupturedplaques

Riskfactors

AgeHyperlipidemiaDiabetesmellitusHypertensionSmokingMalegenderFamilyhistoryofatheroscleroticarterialdisease(inheritance)Inducingfactors

EarlyhoursofthemorningOvereatingHeavyphysicalactivityAgitationRapidriseofbloodpressureDefecatinghardlyShockDehydrationSurgerySeverearrhythmiaSymptomsProdromalsymptoms:PainofinfarctionAssociatedsymptomsPainlessinfarctionsuddendeathandEarlyarrhythmiasProdromalsymptoms

Occuratrestorwithlessactivitythanusual.Approximatelyonethirdhavehadsymptomsfrom1to4weeksbefore.Painofinfarction

AtrestIntheearlymorningSimilartoanginainlocationandradiationbutmoresevere.Nitroglycerinhaslittleeffect,evenopioidmaynotrelievethepain.Associatedsymptoms

coldsweatweakLight-headednessapprehensivesyncopedyspneaorthopneacoughwheezingnauseaandvomitingabdominalbloatingPainlessinfarction

Itisestimatedthatatleast20%ofacuteMIsarepainlessoratypical.ElderlypatientsandpatientswithdiabetesareparticularlypronepainlessoratypicalMI.suddendeathandEarlyarrhythmias

About50%occurbeforethepatientsarriveatthehospitals,withdeathpresumablycausedbyventricularfibrillation.SignsgeneralChestHeartExtremitiesSigns

GeneralAnxiousSweatingprofuselybradycardiaortachycardiaLowcardiacoutputArrhythmiaHighorlowbloodpressureRespiratorydistressFeverSignsChestRale(pulmonaryedema)

KillipclassificationClassI=absenceofRalesClassII=less50%ofthelungfieldsClassIII=over50%ofthelungfieldsClassIV=cardiogenicshock(rales,hypotension,andsignsofhypoperfusion)SignsHeartAbnormallylocatedventricularimpulse

dyskineticinfractedJugularvenousdistensionrightatrialhypertensionSoftheartsoundsleftventriculardysfunctionHeartS4atrialgallopsS3ventriculargallopscardiacinsufficiencymitralregurgitationmurmurpapillarymuscledysfunctionrarelyrupturePericardialfrictionrubsSigns

ExtremitiesEdemaCyanosisandcoldtemperaturelowoutputPeripheralpulsesAuxiliaryexaminationsElectrocadiographyLaboratoryfindingsEchocardiographyElectrocadiogramECGchanges:STsegmentelevationQwavedevelopmentTwaveinversionSTsegmentelevation

QwavedevelopmentTwaveinversion

Location

Inferiorwall——ⅡⅢaVFAnteriorwall——V1－6Anteroseptalwall——V1-3Apicalorlateralwall—V4－6Posteriorwall-----V7-9

Right-sided

----V4R-V5RLaboratoryfindingsMarkerTimetoappearanceDurationofelevation6hr12hrSpecificityTroponinI2-6hr5-10d75%90%-100%98%TroponinT2-6hr5-14d80%95%-100%95%CK-MB3-6hr2-4d65%95%95%myoglobin1-2hr<1d85%90%80%Echocardiography

WHODefinitionOfMIDiagnosisChestpainHistory、examinationandECGAcutecoronarysyndrome〔ACS〕STsegmentelevation

Non-STsegmentelevation

NSTEMIUANoTnI(TnT)STEMITnI(TnT)TnI(TnT)Thedifferentialdiagnosis

AnginaAcutepericarditisAcutepulmonaryembolismAcuteabdominalpainAorticdissectionComplications

DysfunctionorruptureofpapillarymuscleRuptureoftheheartEmbolismCardiacaneurysmPostinfarctionsyndromeTherapyGeneraltreamentmeasuresControlofcardiacpainRecanalizationtherapyControlofarrhythmias

ControlofshockControlofheartfailureOthertherapiesTherapiesofcomplicationsPrevention

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