Bullettin of CMC Alumni Association

	Sign In Sign-Up

Bulletin of CMC Alumni Association

A Publication of Calicut Medical College Alumni Association.

(For Circulation Among Members Only)
See Archives for back issues

Book II No. 2 January 1999

EDITORIAL

A physician should not give, offer, solicit or receive any gift, gratuity, commission or bonus for referring, recommending or procuring any specimen or materials for diagnostic or other study or work".

MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION

- SOME USEFUL TIPS

C. ASHOKAN NAMBIAR, MD;DM;FACC

(Former Professor & Chief of Cardiology, Medical College,Calicut)

Most practitioners of modern medicine are aware of the modern trends in the management of acute myocardial infarction (AMI). However, there are certain aspects which do not find mention in standard textbooks. We learn these things from experience, from discussions with experts and at times from medical journals.The objective of this article is to throw light on some of these facts.

Early Diagnosis:

Time is the essence of preserving myocardium. Time is muscle – cardiac muscle. Very early in the course of AMI all investigations like ECG, cardiac enzymes etc are normal. The commonest mistake I have come across is to diagnose acid peptic disease or dyspepsia in cases of genuine AMI. The remedy is to concentrate on HISTORY. Take targeted history. Ask the patient:-

Where is the discomfort – central chest with or without radiation – consider AMI
Discomfort in arm, neck or back alone – suspect AMI.
What type of discomfort - oppression, pressure, squeezing, heaviness – all suggest AMI
Discomfort of angina is related to effort, but AMI generally occurs at rest – but may occur sometime after strenuous effort.
Sweating,exhaustion, blackout, near blackout (grey out), breathlessness all indicate possibility of AMI.
Relief with antacids: This is a red herring. Since cardiac pain may appear and disappear spontaneously, it may coincide with intake of antacids. So also nitrates may relieve oesophageal spasm – albeit more slowly.
Ask this question always - Especially when the patients tell you I have "gas problem"
ask them – "did you have this particular problem anytime before or is this something new, you are experiencing ? If so suspect AMI especially in a patient with risk factors (age, sex, smoking, diabetes, hypertension etc).

Confirmation:

Once you suspect – AMI, the next task is to confirm it. An elecrocardiogram (ECG) is a must. Early ECG may appear normal at first, but is never really normal. Look carefully for minor changes – subtle ST shift, "T" flattening, reduction in ‘R" voltage etc. If a previous tracing is available, compare carefully. ECG changes appear generally in 4 to 6 hours, and it may be too late for optimal management. If ECG is normal or equivocal, estimate CPK or CKMB or cardiotroponin. There is no use in estimating SGOT or LDH on the first day. Serial values may be useful.

If the history is very typical and the first ECG is normal, it is mandatory to repeat it after 1or 2 hours or when pain recurs.

Management:

If the discomfort is severe, give opiates intravenously along with antihistamines. Do not give IM medications. Administer oxygen and check heart rate and blood pressure frequently. If there is any fall in BP start IV fluids. If AMI is confirmed or most certain, consider thrombolytic treatment. Ask a few questions to yourself:

Are you equipped with facilities to start streptokinase? If so, exclude contraindications, check blood parameters and start treatment immediately.
If there is no facility in your place send the patient as quickly as possible to the nearest hospital where treatment will be given without delay. Always send patients in as stable a condition as possible.
Explain the problem to the patient or relatives clearly and write a proper reference letter mentioning what medications were already given. The risk benefit ratio in each case and with each form of treatment should be discussed properly with the patient and or relatives as the case may be, and documented in order to protect oneself.

Thrombolytic Treatment:

This has revolutionised treatment of AMI and the prognosis has improved tremendously in recent times. The earlier it is administered, the better for the patient. Always AMI should be documented and contraindications avoided. If it can be given in the first hour (golden hour)of AMI, it gives the best results. Benefit decreases linearly, but upto 6 hours, it is still beneficial. After this only those with continuing chest pain or those with extension of MI would benefit. 150mg of Aspirin chewed, gives equally important and additive benefit. Routine anticoagulants after SK is not advised, but high risk patients may benefit with regular or low-molecular weight heparin.

Other Supportive Measures:

Absolute rest and judicious sedation for 24 to 48 hrs and mobilisation after that, if stable is a wise practice. If the patient is unstable one has to wait longer.

Management of various complications of AMI do not fall within the scope of this article. However there are a few tips to prevent long term complications.

Aspirin: to be given long term if tolerated by the patient. 80 to 150 mg/day.

Beta-blockers: Long term administration in appropriate dose, if no contraindication, is beneficial.

ACE inhibitors: In large MI and in patient with left ventricular dysfunction, it should be started in small dose 2-3 days after the onset (when BP is stable) and gradually increase.

Lipid lowering, antioxidants, B vitamins etc are all beneficial in suitable patients.

With elegant and prompt treatment of AMI, the prognosis is quite good, but the greatest problem still is delayed treatment.

Editorial (Contd.)