विवरण
Myocardial ischemia is a lack of blood flow getting to your heart muscle. That means your heart muscle isn’t getting enough blood to do what it needs to do. Often, the cause is a collection of fat and cholesterol (plaque) that doesn’t let enough blood go through your coronary arteries. Medicines and surgeries can treat myocardial ischemia. Each year, more than 1 million people in the United States die from myocardial infarction (heart attack). This is due to myocardial ischemia, a lack of blood flow and oxygen to your heart muscle.
सारांश
- Rapid recognition of Acute Coronary Syndrome (ACS) is crucial in the emergency department. Differentiate ACS from other chest pain causes, create a differential diagnosis, and minimize hospitalization costs and patient burden. The "golden hour" concept highlights the importance of timely intervention, such as thrombolysis or angioplasty, to improve patient outcomes.
- Initial investigations for chest pain should include a 12-lead ECG, lipid profile, thyroid function test, echocardiogram, cardiac biomarkers, CBC, metabolic panel, and chest X-ray. Focus assessment on chest pain characteristics, localization, type, radiation, and associated symptoms like sweating. Evaluate peripheral pulses and assess cardiovascular risk factors using tools like the GRACE index or TIMI score.
- Treatment strategies for ACS depend on the ECG findings. For ST-elevation MI (STEMI), prompt thrombolysis or primary percutaneous coronary intervention (PCI) is required, ideally within three hours. Non-ST elevation MI (NSTEMI) necessitates antiplatelet, anti-ischemic, and anticoagulant therapy. Avoid thrombolysis in NSTEMI cases.
- ECG interpretation includes assessing for ST changes, hyperacute T waves, and new-onset Left Bundle Branch Block (LBBB), which can indicate a deteriorating condition. Complement ECG findings with echocardiography to identify regional wall motion abnormalities and assess left ventricular dysfunction. Use biomarkers like troponin to support the diagnosis. Serial troponin measurements at 0, 6, 12, and 24 hours are recommended. Negative troponin levels after 24 hours can help rule out MI.
- Initial management focuses on airway, breathing, and circulation. Stabilize blood pressure and maintain adequate oxygenation, but avoid unnecessary oxygen administration if SpO2 is above 92-94%. Remember the "MONA" mnemonic for initial treatment: Morphine for pain relief, Oxygen to maintain oxygenation, Nitroglycerin for ischemic pain and BP control, and Antiplatelets like clopidogrel or ticagrelor.
- If STEMI is diagnosed and a cath lab is accessible, immediate transfer for primary PCI is the preferred approach. In rural settings with limited access, thrombolysis can be considered if the patient is within the appropriate time window. Assess contraindications for thrombolysis before administration. Fibrinolytic agents like streptokinase or tenecteplase can be used, with tenecteplase offering advantages but potential for allergic reactions.
- After stabilization, continue antiplatelet therapy and manage other comorbidities. In cases of triple vessel disease or Left Main Coronary Artery (LMCA) blockage, coronary artery bypass grafting (CABG) may be necessary. Beta-blockers are beneficial for reducing ischemic risk and improving mortality. Manage associated heart failure with appropriate medications. Long-term management involves lifestyle modifications and risk factor management.
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