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1
Erlinge, David, and Göran Olivecrona. Diagnosis and management of ST-elevation of myocardial infarction. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0147.
Full textAbstract:
ST-elevation myocardial infarction (STEMI) is generally caused by a ruptured plaque that triggers local thrombus formation, which occludes the coronary artery. STEMI should be diagnosed rapidly, based on the combination of ST-segment elevation and symptoms of acute myocardial infarction. The main treatment objective is myocardial tissue reperfusion as quickly as possible. The preferred method of reperfusion is primary percutaneous coronary interventionif transport time is below 2 hours, and thrombolysis if longer STEMI patients with acute onset cardiogenic shock should be evaluated by echocardiography to exclude mechanical complications, such as flail mitral insufficiency, ventricular septal defect or tamponade. Secondary prevention includes aspirin, adenosine diphosphate receptor antagonists, statins, beta-blockers, angiotensin-converting enzymeinhibitors, and lifestyle changes.
2
Shirodaria, Cheerag, and Sam Dawkins. Acute coronary syndromes. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0090.
Full textAbstract:
The term ‘acute coronary syndrome’ includes unstable angina, ST-elevation myocardial infarction (STEMI), and non-ST-elevation myocardial infarction (NSTEMI). The difference between these three syndromes is as follows. In STEMI and NSTEMI, there is evidence of myocardial necrosis, as evidenced by raised cardiac enzymes, specifically, the very sensitive cardiac biomarker troponin. STEMI is diagnosed when the ECG shows persisting ST elevation in an appropriate territory consistent with STEMI whereas, in NSTEMI, there can be any or no ECG changes, or very transient, self-limiting ST elevation. In unstable angina, there is no myocardial necrosis, and troponins are normal. The ECG is as for NSTEMI and often shows no change, ST depression, or T-wave inversion. The prognoses in STEMI and NSTEMI are identical; unstable angina has a better prognosis than either STEMI or NSTEMI.
3
Huber, Kurt, and Tom Quinn. Systems of care for patients with acute ST elevation myocardial infarction (STEMI networks). Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0042.
Full textAbstract:
Although primary percutaneous coronary intervention is the preferred strategy for patients with ST elevation myocardial infarction, offering a fast access to this procedure often remains difficult, because of local resources and capabilities and a lack of cooperation and organization. Accordingly, for most countries worldwide, primary percutaneous coronary intervention can be provided for only part of the population. Moreover, not all patients referred for primary percutaneous coronary intervention receive an optimal mechanical reperfusion within the recommended time intervals with the procedure performed in an experienced centre by an experienced team. Intravenous thrombolytic therapy, preferably administered pre-hospital and as part of a pharmacoinvasive strategy, offers a reasonable therapeutic option in selected cases. Network organization is central to offering fast and optimal reperfusion treatment in the individual case. It has been shown repeatedly that an early recognition of ST elevation myocardial infarction, as well as minimizing time delays, is important for the achievement of optimal clinical results. These findings should encourage the building up of regional networks, according to specific local constraints, and the monitoring of their effectiveness by ongoing registries. Financial, regulatory, and political barriers can be resolved, and a prompt guideline-recommended care becomes feasible and affordable if stakeholders and participants agree and cooperate.
4
Huber, Kurt, and Tom Quinn. Systems of care for patients with acute ST elevation myocardial infarction (STEMI networks). Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0042_update_001.
Full textAbstract:
Although primary percutaneous coronary intervention is the preferred strategy for patients with ST elevation myocardial infarction, offering a fast access to this procedure often remains difficult, because of local resources and capabilities and a lack of cooperation and organization. Accordingly, for most countries worldwide, primary percutaneous coronary intervention can be provided for only part of the population. Moreover, not all patients referred for primary percutaneous coronary intervention receive an optimal mechanical reperfusion within the recommended time intervals with the procedure performed in an experienced centre by an experienced team. Intravenous thrombolytic therapy, preferably administered pre-hospital and as part of a pharmacoinvasive strategy, offers a reasonable therapeutic option in selected cases. Network organization is central to offering fast and optimal reperfusion treatment in the individual case. It has been shown repeatedly that an early recognition of ST elevation myocardial infarction, as well as minimizing time delays, is important for the achievement of optimal clinical results. These findings should encourage the building up of regional networks, according to specific local constraints, and the monitoring of their effectiveness by ongoing registries. Financial, regulatory, and political barriers can be resolved, and a prompt guideline-recommended care becomes feasible and affordable if stakeholders and participants agree and cooperate.
5
Huber, Kurt, and Tom Quinn. Systems of care for patients with acute ST elevation myocardial infarction (STEMI networks). Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0042_update_002.
Full textAbstract:
Although primary percutaneous coronary intervention is the preferred strategy for patients with ST elevation myocardial infarction, offering a fast access to this procedure often remains difficult, because of local resources and capabilities and a lack of cooperation and organization. Accordingly, for most countries worldwide, primary percutaneous coronary intervention can be provided for only part of the population. Moreover, not all patients referred for primary percutaneous coronary intervention receive an optimal mechanical reperfusion within the recommended time intervals with the procedure performed in an experienced centre by an experienced team. Intravenous thrombolytic therapy, preferably administered pre-hospital and as part of a pharmacoinvasive strategy, offers a reasonable therapeutic option in selected cases. Network organization is central to offering fast and optimal reperfusion treatment in the individual case. It has been shown repeatedly that an early recognition of ST elevation myocardial infarction, as well as minimizing time delays, is important for the achievement of optimal clinical results. These findings should encourage the building up of regional networks, according to specific local constraints, and the monitoring of their effectiveness by ongoing registries. Financial, regulatory, and political barriers can be resolved, and a prompt guideline-recommended care becomes feasible and affordable if stakeholders and participants agree and cooperate.
6
D’Auria, Stephen, and Ravi Ramani. Chest Pain and Acute Coronary Syndrome (DRAFT). Edited by Raghavan Murugan and Joseph M. Darby. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190612474.003.0011.
Full textAbstract:
Chest pain is a common presenting complaint faced by the rapid response team (RRT), and can herald a serious process such as acute coronary syndrome or aortic dissection, or be secondary to a minor muscle strain. A methodical approach to chest pain is necessary to avoid premature diagnostic closure. One of the most feared diagnoses is a myocardial infarction. Fortunately, there are well-established guidelines describing the necessary steps for treatment of both ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). This chapter will address the differential for chest pain as well as established guidelines for treatment of acute coronary syndrome.
7
Erlinge, David, and Göran Olivecrona. Diagnosis and management of non-STEMI coronary syndromes. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0146.
Full textAbstract:
Acute coronary syndromes are classified as ST segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) or unstable angina. Most patients with NSTEMI present with a history of chest pain that has subsided spontaneously before or soon after arrival at the emergency room, but with positive cardiac markers (usually troponin T or I) indicative of myocardial infarction. NSTEMI has a risk of recurrent myocardial infarction of 15–20% and a 15% chance of 1-year mortality. Patients with non-STE-acute coronary syndromes are at similar risk as a STEMI patient at 1 year. The strongest objective signs of NSTEMI are a positive troponin and ST segment depression. NSTEMI should be acutely treated with aspirin, an adenosine diphosphate-receptor antagonist, and an anticoagulant (fondaparinux or low molecular weight heparins). NSTEMI should be investigated with coronary angiography within 72 hours. Curative treatment is percutaneous coronary intervention or coronary artery bypass grafting.
8
Dawson, Dana, and Keith Fox. Anti-Platelet and Anti-Thrombotic Therapy Post-AMI. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199544769.003.0004.
Full textAbstract:
• Acute coronary syndromes (ACS) encompass a spectrum of presentations which include unstable angina, non-ST-elevation myocardial infarction (NSTEMI or NSTE-ACS), and ST-elevation myocardial infarction (STEMI or STE-ACS)• Anti-platelet and anti-thrombotic agents are administered as ancillary therapy to myocardial reperfusion in patients presenting with an acute coronary syndrome, to maintain the patency of the infarct-related coronary artery• More specific and potent inhibitors of platelet activation and of the coagulation cascade are emerging with the aim being to further improve clinical outcomes in patients presenting with an acute coronary syndrome, without increasing the risks of major bleeding.
9
AlJaroudi, Wael. Risk Assessment in Acute Coronary Syndromes. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199392094.003.0013.
Full textAbstract:
Acute coronary syndromes (ACS) include unstable angina pectoris (UAP), non-ST elevation (NSTEMI), and ST elevation acute myocardial infarction (STEMI). Each year, more than 2 million people are hospitalized with ACS in the United States. The initial treatment has evolved over the last few decades from conservative management to early reperfusion therapy. Medical therapy has also significantly changed with the use of newer more potent antiplatelet agents, beta-blockers, angiotensin converting enzyme inhibitors, statins, and anti-anginal drugs, which have resulted in improvement of patient care and survival. There is no role for stress myocardial perfusion imaging (MPI) in the acute presentation; however, rest MPI may be used to identify the culprit lesion and risk stratify patients if injected during chest pain. In stable patients for ACS, submaximal exercise or vasodilator MPI can be performed as early as 48 hours after the event. Several gated MPI-derived variables such as left ventricular (LV) ejection fraction (EF), LV volumes, infarct size, mechanical dyssynchrony, and residual ischemic burden can risk stratify patients and provide prognostic data incremental to validated clinical risk scores such as GRACE (Global Registry of Acute Coronary Syndrome) and TIMI (Thrombolysis in Myocardial Infarction). Patients with depressed LVEF, remodeled LV, and large perfusion defects are at particularly high- risk for subsequent cardiac death or recurrent myocardial infarction. In such setting, MPI plays a pivotal role in the management of patients and guiding therapeutic decisions. The current chapter will review the clinical and MPI predictors of outcomes in patients presenting with ACS according to updated guidelines and a proposed algorithm integrating the role of MPI in guiding therapeutic decisions and management.
10
Kisiel, Maria, and Alison Smith. Cardiac surgery. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199642663.003.0026.
Full textAbstract:
Coronary heart disease is caused by the build-up of atherosclerotic plaques which, over time, narrow the lumen of the coronary arteries. Acute coronary syndrome describes a spectrum of conditions caused by coronary artery disease; these are unstable angina, ST-elevation myocardial infarction (STEMI), and non-ST-elevation myocardial infarction (NSTEMI). Coronary artery disease is the leading cause for cardiac surgical interventions, but other causes are hypertension, valve disease, arrhythmias, cardiomyopathies, infections, and congenital abnormalities. This chapter provides an overview of the signs and symptoms of these conditions, as well as the diagnosis and treatment options available.
11
Cheong, Adrian, Gabriel Steg, and Stefan K. James. ST-segment elevation myocardial infarction. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0043.
Full textAbstract:
Acute myocardial infarction with ST-segment elevation is a common and dramatic manifestation of coronary artery disease. It is caused by the rupture of an atherosclerotic plaque in a coronary artery, leading to its total thrombotic occlusion and resultant ischaemia and necrosis of downstream myocardium. The diagnosis of ST-segment elevation myocardial infarction is based on a syndrome of ischaemic chest pain symptoms, associated with typical ST-segment elevation on the electrocardiogram and an eventual rise in biomarkers of myocardial necrosis. The treatment of ST-segment elevation myocardial infarction is focused on re-establishing blood flow in the coronary artery involved, preferably by percutaneous coronary intervention, or by pharmacological thrombolysis in the case of expected lengthy time delays or lack of availability of facilities. Early mortality from ST-segment elevation myocardial infarction can be attributed to the sequelae or complications of myocardial ischaemia, or complications related to therapy. The former include arrhythmias (such as ventricular tachycardia or fibrillation), mechanical complications (such as ventricular free wall, septal, and mitral chordal rupture), and pump failure leading to cardiogenic shock. The latter includes haemorrhagic complications and coronary stent thrombosis. Given that myocardial necrosis is a critically time-dependent process, the organization of an ST-segment elevation myocardial infarction care system and adherence to the latest clinical trial evidence and guidelines are crucial to ensure that patients are treated in an optimal manner.
12
Katritsis, Demosthenes G., Bernard J. Gersh, and A. John Camm. Acute myocardial infarction. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199685288.003.0596_update_004.
Full textAbstract:
Diagnosis and current therapy of ST elevation myocardial infarction are presented. Recent recommendations by the ACC/AHA and the ESC on primary PCI and fibrinolysis have been summarized and tabulated.
13
Hoque, Azizul, Chowdhury Ahsan, and Aaysha Cader. Handbook of Management of Acute ST-Elevation Myocardial Infarction. BD Physicians, 2021.
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14
Katritsis, Demosthenes G., Bernard J. Gersh, and A. John Camm. Non-ST elevation acute coronary syndromes. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199685288.003.0538_update_004.
Full textAbstract:
Diagnosis and current pharmacological and interventional management of unstable angina/non-ST elevation myocardial infarction are presented in this chapter. Recent recommendations by the ACC/AHA and the ESC have been summarized and tabulated.
15
Bueno, Héctor, and José A. Barrabés. Non-ST-segment elevation acute coronary syndromes. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0046.
Full textAbstract:
Non-ST-segment elevation acute coronary syndromes are life-threatening disorders, usually caused by acute coronary thrombosis and subsequent myocardial ischaemia, presenting without persistent ST-segment elevation in the initial electrocardiogram. According to the occurrence of myocardial necrosis, non-ST-segment elevation acute coronary syndromes are divided into non-ST-segment myocardial infarction or unstable angina. The management of non-ST-segment elevation acute coronary syndromes requires an early diagnosis and risk stratification, urgent hospitalization, monitoring, and medical treatment, including antithrombotic therapy with dual antiplatelet therapy (aspirin plus one P2Y12 inhibitor) and parenteral anticoagulation, anti-ischaemic treatment, and preventative therapies. After the initial medical therapy is established, an invasive strategy, consisting of coronary angiography with coronary revascularization (either percutaneous coronary intervention or coronary bypass graft surgery), as appropriate, should be decided. The timing of the invasive strategy should be adjusted, according to the patient’s risk. Given the high event rate of patients with non-ST-segment elevation acute coronary syndromes after hospital discharge, an aggressive long-term preventative therapy should be put in place to improve prognosis.
16
Bueno, Héctor, and José A. Barrabés. Non-ST-segment elevation acute coronary syndromes. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0046_update_001.
Full textAbstract:
Non-ST-segment elevation acute coronary syndromes are life-threatening disorders, usually caused by acute coronary thrombosis and subsequent myocardial ischaemia, presenting without persistent ST-segment elevation in the initial electrocardiogram. According to the occurrence of myocardial necrosis, non-ST-segment elevation acute coronary syndromes are divided into non-ST-segment myocardial infarction or unstable angina. The management of non-ST-segment elevation acute coronary syndromes requires an early diagnosis and risk stratification, urgent hospitalization, monitoring, and medical treatment, including antithrombotic therapy with dual antiplatelet therapy (aspirin plus one P2Y12 inhibitor) and parenteral anticoagulation, anti-ischaemic treatment, and preventative therapies. After the initial medical therapy is established, an invasive strategy, consisting of coronary angiography with coronary revascularization (either percutaneous coronary intervention or coronary bypass graft surgery), as appropriate, should be decided. The timing of the invasive strategy should be adjusted, according to the patient’s risk. Given the high event rate of patients with non-ST-segment elevation acute coronary syndromes after hospital discharge, an aggressive long-term preventative therapy should be put in place to improve prognosis.
17
Bueno, Héctor, and José A. Barrabés. Non-ST-segment elevation acute coronary syndromes. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0046_update_002.
Full textAbstract:
Non-ST-segment elevation acute coronary syndromes are life-threatening disorders, usually caused by acute coronary thrombosis and subsequent myocardial ischaemia, presenting without persistent ST-segment elevation in the initial electrocardiogram. According to the occurrence of myocardial necrosis, non-ST-segment elevation acute coronary syndromes are divided into non-ST-segment myocardial infarction or unstable angina. The management of non-ST-segment elevation acute coronary syndromes requires an early diagnosis and risk stratification, urgent hospitalization, monitoring, and medical treatment, including antithrombotic therapy with dual antiplatelet therapy (aspirin plus one P2Y12 inhibitor) and parenteral anticoagulation, anti-ischaemic treatment, and preventative therapies. After the initial medical therapy is established, an invasive strategy, consisting of coronary angiography with coronary revascularization (either percutaneous coronary intervention or coronary bypass graft surgery), as appropriate, should be decided. The timing of the invasive strategy should be adjusted, according to the patient’s risk. Given the high event rate of patients with non-ST-segment elevation acute coronary syndromes after hospital discharge, an aggressive long-term preventative therapy should be put in place to improve prognosis.
18
Cheong, Adrian P., Gabriel Steg, and Stefan K. James. ST-segment elevation MI. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0043_update_001.
Full textAbstract:
Acute myocardial infarction with ST-segment elevation is a common and dramatic manifestation of coronary artery disease. It is caused by the rupture of an atherosclerotic plaque in a coronary artery, leading to its total thrombotic occlusion and resultant ischaemia and necrosis of downstream myocardium. The diagnosis of ST-segment elevation myocardial infarction is based on a syndrome of ischaemic chest pain symptoms, associated with typical ST-segment elevation on the electrocardiogram and an eventual rise in biomarkers of myocardial necrosis. The treatment of ST-segment elevation myocardial infarction is focused on re-establishing blood flow in the coronary artery involved, preferably by percutaneous coronary intervention, or by pharmacological thrombolysis in the case of expected lengthy time delays or lack of availability of facilities. Early mortality from ST-segment elevation myocardial infarction can be attributed to the sequelae or complications of myocardial ischaemia, or complications related to therapy. The former include arrhythmias (such as ventricular tachycardia or fibrillation), mechanical complications (such as ventricular free wall, septal, and mitral chordal rupture), and pump failure leading to cardiogenic shock. The latter includes haemorrhagic complications and coronary stent thrombosis. Given that myocardial necrosis is a critically time-dependent process, the organization of an ST-segment elevation myocardial infarction care system and adherence to the latest clinical trial evidence and guidelines are crucial to ensure that patients are treated in an optimal manner.
19
Valgimigli, Marco, and Marco Angelillis. Treatment of non-ST elevation acute coronary syndromes. Edited by Stefan James. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198784906.003.0311.
Full textAbstract:
Treatment of patients presenting with a non-ST elevation acute coronary syndrome (NSTE-ACS) aims at immediate relief of ischaemia and the prevention of serious adverse events, including death, myocardial (re)infarction, and life-threatening arrhythmias. In NSTE-ACS, patient management is guided by risk stratification (troponin, electrocardiogram, risk scores, etc.). Treatment options include anti-ischaemic and antithrombotic drugs and coronary revascularization including percutaneous coronary interventions, or coronary artery bypass grafting. While long-term secondary prevention with aspirin monotherapy is currently the gold standard approach for all NSTE-ACS patients who tolerate the drug, additional medications on top of aspirin such as oral P2Y12 inhibitors or oral anticoagulation have been investigated across clinical trials and their long-term use should be guided by the ischaemic versus bleeding risk status of each single individual patient.
20
López-Sendón, José, and Esteban López de Sá. Mechanical complications of myocardial infarction. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0045.
Full textAbstract:
Mechanical complications after an acute infarction include different forms of heart rupture, including free wall rupture, interventricular septal rupture, and papillary muscle rupture. Its incidence decreased dramatically with the widespread use of reperfusion therapies but may occur in 2–3% of ST-elevation myocardial infarction patients, and mortality is very high if not properly diagnosed, as surgery is the only effective treatment. Echocardiography is the most important tool for diagnosis that should be suspected in patients with hypotension, heart failure, or recurrent chest pain. Awareness and well-established protocols are crucial for an early diagnosis. Modern imaging techniques permit a more reliable and direct identification of left ventricular free wall rupture, which is almost impossible to identify with conventional echocardiography. Mitral regurgitation, secondary to papillary muscle ischaemia or necrosis or left ventricular dilatation and remodelling, without papillary muscle rupture, is frequent after myocardial infarction and is considered as an independent risk factor for outcomes. Revascularization to control ischaemia and surgical repair should be considered in all patients with severe or symptomatic mitral regurgitation in the absence of severe left ventricular dysfunction. Other mechanical complications include true aneurysms and thrombus formation in the left ventricle. Again, these complications have decreased with the use of early reperfusion therapies and, for thrombus formation, with aggressive antithrombotic treatment. In a single large randomized trial (STICH), surgical remodelling of the left ventricle failed to demonstrate a significant improvement in outcomes, although it still may be an option in selected patients.
21
López-Sendón, José, and Esteban López de Sá. Mechanical complications of myocardial infarction. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0045_update_001.
Full textAbstract:
Mechanical complications after an acute infarction include different forms of heart rupture, including free wall rupture, interventricular septal rupture, and papillary muscle rupture. Its incidence decreased dramatically with the widespread use of reperfusion therapies but may occur in 2–3% of ST-elevation myocardial infarction patients, and mortality is very high if not properly diagnosed, as surgery is the only effective treatment. Echocardiography is the most important tool for diagnosis that should be suspected in patients with hypotension, heart failure, or recurrent chest pain. Awareness and well-established protocols are crucial for an early diagnosis. Modern imaging techniques permit a more reliable and direct identification of left ventricular free wall rupture, which is almost impossible to identify with conventional echocardiography. Mitral regurgitation, secondary to papillary muscle ischaemia or necrosis or left ventricular dilatation and remodelling, without papillary muscle rupture, is frequent after myocardial infarction and is considered as an independent risk factor for outcomes. Revascularization to control ischaemia and surgical repair should be considered in all patients with severe or symptomatic mitral regurgitation in the absence of severe left ventricular dysfunction. Other mechanical complications include true aneurysms and thrombus formation in the left ventricle. Again, these complications have decreased with the use of early reperfusion therapies and, for thrombus formation, with aggressive antithrombotic treatment. In a single large randomized trial (STICH), surgical remodelling of the left ventricle failed to demonstrate a significant improvement in outcomes, although it still may be an option in selected patients.
22
López-Sendón, José, and Esteban López de Sá. Mechanical complications of myocardial infarction. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199687039.003.0045_update_002.
Full textAbstract:
Mechanical complications after an acute infarction include different forms of heart rupture, including free wall rupture, interventricular septal rupture, and papillary muscle rupture. Its incidence decreased dramatically with the widespread use of reperfusion therapies but may occur in 2–3% of ST-elevation myocardial infarction patients, and mortality is very high if not properly diagnosed, as surgery is the only effective treatment. Echocardiography is the most important tool for diagnosis that should be suspected in patients with hypotension, heart failure, or recurrent chest pain. Awareness and well-established protocols are crucial for an early diagnosis. Modern imaging techniques permit a more reliable and direct identification of left ventricular free wall rupture, which is almost impossible to identify with conventional echocardiography. Mitral regurgitation, secondary to papillary muscle ischaemia or necrosis or left ventricular dilatation and remodelling, without papillary muscle rupture, is frequent after myocardial infarction and is considered as an independent risk factor for outcomes. Revascularization to control ischaemia and surgical repair should be considered in all patients with severe or symptomatic mitral regurgitation in the absence of severe left ventricular dysfunction. Other mechanical complications include true aneurysms and thrombus formation in the left ventricle. Again, these complications have decreased with the use of early reperfusion therapies and, for thrombus formation, with aggressive antithrombotic treatment. In a single large randomized trial (STICH), surgical remodelling of the left ventricle failed to demonstrate a significant improvement in outcomes, although it still may be an option in selected patients.
23
López-Sendón, José, and Esteban López de Sá. Mechanical complications of myocardial infarction. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0045_update_003.
Full textAbstract:
Mechanical complications after an acute infarction involve different forms of heart rupture, including free wall rupture, interventricular septal rupture, and papillary muscle rupture. Its incidence decreased dramatically with the widespread use of reperfusion therapies occurring in <1% of ST-elevation myocardial infarction patients, and mortality is very high if not properly diagnosed, as surgery is the only effective treatment (Ibanez et al, 2017). Echocardiography is the most important tool for diagnosis that should be suspected in patients with hypotension, heart failure, or recurrent chest pain. Awareness and well-established protocols are crucial for an early diagnosis. Modern imaging techniques permit a more reliable and direct identification of left ventricular free wall rupture, which is almost impossible to identify with conventional echocardiography. Mitral regurgitation, secondary to papillary muscle ischaemia or necrosis or left ventricular dilatation and remodelling, without papillary muscle rupture, is frequent after myocardial infarction and is considered as an independent risk factor for outcomes. Revascularization to control ischaemia and surgical repair should be considered in all patients with severe or symptomatic mitral regurgitation in the absence of severe left ventricular dysfunction. Other mechanical complications include true aneurysms and thrombus formation in the left ventricle. Again, these complications have decreased with the use of early reperfusion therapies and, for thrombus formation, with aggressive antithrombotic treatment. In a single large randomized trial (STICH), surgical remodelling of the left ventricle failed to demonstrate a significant improvement in outcomes, although it still may be an option in selected patients.
24
Kočka, Viktor, Steen Dalby Kristensen, William Wijns, Petr Toušek, and Petr Widimský. Percutaneous coronary interventions in acute coronary syndromes. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0047.
Full textAbstract:
Three different guidelines of the European Society of Cardiology cover the field of percutaneous coronary interventions. Their main recommendations are the following:All patients with an ST-segment elevation myocardial infarction should undergo immediate coronary angiography and percutaneous coronary intervention as soon as possible after the first medical contact. Thrombolysis can be used as an alternative reperfusion therapy if the time delay to primary percutaneous coronary intervention is more than 2 hoursPatients with very high-risk non-ST-segment elevation acute coronary syndromes (recurrent or ongoing chest pain, profound or dynamic electrocardiogram changes, major arrhythmias, or haemodynamic instability) should undergo urgent coronary angiography within less than 2 hours after the initial hospital admissionAll moderate- to high-risk (GRACE score >140 or at least one primary high-risk criterion) non-ST-segment elevation acute coronary syndromes patients should undergo coronary angiography before discharge; the ideal timing is within 24 hours after admission for high-risk groups, and within 72 hours for moderate-risk groupsOther patients with recurrent symptoms or at least one high-risk criterion should undergo coronary angiography within 72 hours of first presentationLow-risk non-ST-segment elevation acute coronary syndromes may be treated conservatively, and the indication for an invasive evaluation can be done, based on the evidence of ischaemia during exercise stress testingStents should be used during all percutaneous coronary intervention procedures, whenever technically feasible. Second-generation drug-eluting stents do not increase stent thrombosis and can be safely used in the ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndrome settingsTriple pharmacotherapy, consisting of aspirin, thienopyridine antiplatelet agent, and anticoagulation with heparin or bivalirudin, should be used in all percutaneous coronary intervention procedures, with glycoprotein IIb/IIIa inhibitors added in patients with a high thrombus burden and low bleeding risk
25
Kočka, Viktor, Steen Dalby Kristensen, William Wijns, Petr Toušek, and Petr Widimský. Percutaneous coronary interventions in acute coronary syndromes. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0047_update_001.
Full textAbstract:
Three different guidelines of the European Society of Cardiology cover the field of percutaneous coronary interventions. Their main recommendations are the following:All patients with an ST-segment elevation myocardial infarction should undergo immediate coronary angiography and percutaneous coronary intervention as soon as possible after the first medical contact. Thrombolysis can be used as an alternative reperfusion therapy if the time delay to primary percutaneous coronary intervention is more than 2 hoursPatients with very high-risk non-ST-segment elevation acute coronary syndromes (recurrent or ongoing chest pain, profound or dynamic electrocardiogram changes, major arrhythmias, or haemodynamic instability) should undergo urgent coronary angiography within less than 2 hours after the initial hospital admissionAll moderate- to high-risk (GRACE score >140 or at least one primary high-risk criterion) non-ST-segment elevation acute coronary syndromes patients should undergo coronary angiography before discharge; the ideal timing is within 24 hours after admission for high-risk groups, and within 72 hours for moderate-risk groupsOther patients with recurrent symptoms or at least one high-risk criterion should undergo coronary angiography within 72 hours of first presentationLow-risk non-ST-segment elevation acute coronary syndromes may be treated conservatively, and the indication for an invasive evaluation can be done, based on the evidence of ischaemia during exercise stress testingStents should be used during all percutaneous coronary intervention procedures, whenever technically feasible. Second-generation drug-eluting stents do not increase stent thrombosis and can be safely used in the ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndrome settingsTriple pharmacotherapy, consisting of aspirin, thienopyridine antiplatelet agent, and anticoagulation with heparin or bivalirudin, should be used in all percutaneous coronary intervention procedures, with glycoprotein IIb/IIIa inhibitors added in patients with a high thrombus burden and low bleeding risk
26
Kočka, Viktor, Steen Dalby Kristensen, William Wijns, Petr Toušek, and Petr Widimský. Percutaneous coronary interventions in acute coronary syndromes. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199687039.003.0047_update_002.
Full textAbstract:
Three different guidelines of the European Society of Cardiology cover the field of percutaneous coronary interventions. Their main recommendations are the following: All patients with an ST-segment elevation myocardial infarction should undergo immediate coronary angiography and percutaneous coronary intervention as soon as possible after the first medical contact. Thrombolysis can be used as an alternative reperfusion therapy if the time delay to primary percutaneous coronary intervention is more than 2 hours. Patients with very high-risk non-ST-segment elevation acute coronary syndromes (recurrent or ongoing chest pain, profound or dynamic electrocardiogram changes, major arrhythmias, or haemodynamic instability) should undergo urgent coronary angiography within less than 2 hours after the initial hospital admissionAll moderate- to high-risk (GRACE score >140 or at least one primary high-risk criterion) non-ST-segment elevation acute coronary syndromes patients should undergo coronary angiography before discharge; the ideal timing is within 24 hours after admission for high-risk groups, and within 72 hours for moderate-risk groups. Other patients with recurrent symptoms or at least one high-risk criterion should undergo coronary angiography within 72 hours of first presentation. Low-risk non-ST-segment elevation acute coronary syndromes may be treated conservatively, and the indication for an invasive evaluation can be done, based on the evidence of ischaemia during exercise stress testing. Stents should be used during all percutaneous coronary intervention procedures, whenever technically feasible. Second-generation drug-eluting stents do not increase stent thrombosis and can be safely used in the ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndrome settings. Triple pharmacotherapy, consisting of aspirin, thienopyridine antiplatelet agent, and anticoagulation with heparin or bivalirudin, should be used in all percutaneous coronary intervention procedures, with glycoprotein IIb/IIIa inhibitors added in patients with a high thrombus burden and low bleeding risk.
27
Kočka, Viktor, Steen Dalby Kristensen, William Wijns, Petr Toušek, and Petr Widimský. Percutaneous coronary interventions in acute coronary syndromes. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0047_update_003.
Full textAbstract:
Three different guidelines of the European Society of Cardiology cover the field of percutaneous coronary interventions. Their main recommendations are the following: All patients with an ST-segment elevation myocardial infarction should undergo immediate coronary angiography and percutaneous coronary intervention as soon as possible after the first medical contact. Thrombolysis can be used as an alternative reperfusion therapy if the time delay to primary percutaneous coronary intervention is more than 2 hours. Patients with very high-risk non-ST-segment elevation acute coronary syndromes (recurrent or ongoing chest pain, profound or dynamic electrocardiogram changes, major arrhythmias, or haemodynamic instability) should undergo urgent coronary angiography within less than 2 hours after the initial hospital admissionAll moderate- to high-risk (GRACE score >140 or at least one primary high-risk criterion) non-ST-segment elevation acute coronary syndromes patients should undergo coronary angiography before discharge; the ideal timing is within 24 hours after admission for high-risk groups, and within 72 hours for moderate-risk groups. Other patients with recurrent symptoms or at least one high-risk criterion should undergo coronary angiography within 72 hours of first presentation. Low-risk non-ST-segment elevation acute coronary syndromes may be treated conservatively, and the indication for an invasive evaluation can be done, based on the evidence of ischaemia during exercise stress testing. Stents should be used during all percutaneous coronary intervention procedures, whenever technically feasible. Second-generation drug-eluting stents do not increase stent thrombosis and can be safely used in the ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndrome settings. Triple pharmacotherapy, consisting of aspirin, thienopyridine antiplatelet agent, and anticoagulation with heparin or bivalirudin, should be used in all percutaneous coronary intervention procedures, with glycoprotein IIb/IIIa inhibitors added in patients with a high thrombus burden and low bleeding risk.
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Katritsis, Demosthenes G., Bernard J. Gersh, and A. John Camm. Epidemiology and pathophysiology of coronary artery disease. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199685288.003.0529_update_004.
Full textAbstract:
This chapter presents the epidemiology and pathophysiology of stable ischaemic heart disease and acute coronary syndromes, i.e. unstable angina/non-ST elevation myocardial infarction and ST elevation myocardial infarction.
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Sinnaeve, Peter, and Frans Van de Werf. Fibrinolytic, antithrombotic, and antiplatelet drugs in acute coronary syndromes. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0044.
Full textAbstract:
Antithrombotic therapy is a major cornerstone in the treatment for acute coronary syndromes, as thrombus formation upon a plaque rupture or an erosion plays a pivotal role in non-ST-segment elevation as well as ST-segment elevation acute coronary syndromes. Both acute and long-term oral antiplatelet therapies, targeting specific platelet activation pathways, have demonstrated significant short- and long-term benefits. The use of anticoagulants is currently largely confined to the acute setting, except in patients with a clear indication for long-term treatment, including atrial fibrillation or the presence of intraventricular thrombi. Despite the benefit of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction, fibrinolysis continues to play an important role throughout the world as well. In this chapter, the fibrinolytic, antiplatelet, and anticoagulant agents used in the management of acute coronary syndrome patients are discussed.
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Sinnaeve, Peter, and Frans Van de Werf. Fibrinolytic, antithrombotic, and antiplatelet drugs in acute coronary syndromes. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0044_update_001.
Full textAbstract:
Antithrombotic therapy is a major cornerstone in the treatment for acute coronary syndromes, as thrombus formation upon a plaque rupture or an erosion plays a pivotal role in non-ST-segment elevation as well as ST-segment elevation acute coronary syndromes. Both acute and long-term oral antiplatelet therapies, targeting specific platelet activation pathways, have demonstrated significant short- and long-term benefits. The use of anticoagulants is currently largely confined to the acute setting, except in patients with a clear indication for long-term treatment, including atrial fibrillation or the presence of intraventricular thrombi. Despite the benefit of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction, fibrinolysis continues to play an important role throughout the world as well. In this chapter, the fibrinolytic, antiplatelet, and anticoagulant agents used in the management of acute coronary syndrome patients are discussed.
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Ramrakha, Punit, and Jonathan Hill, eds. Cardiovascular emergencies. Oxford University Press, 2012. http://dx.doi.org/10.1093/med/9780199643219.003.0017.
Full textAbstract:
Adult basic life support 710Adult advanced life support 712Universal treatment algorithm 716Primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction 718Acute MI: thrombolysis protocol 719Acute myocardial infarction 720Treatment options in tachyarrhythmias 721Ventricular tachycardia: drugs 722Supraventricular tachyarrhythmias ...
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Banerjee, Ashis, and Clara Oliver. Cardiac emergencies. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198786870.003.0009.
Full textAbstract:
Chest pain is a common presenting complaint for patients in the emergency department. This chapter focuses on the management and recent changes to non-ST-segment elevation myocardial infarction (NSTEMI) and STEMI pathways, in keeping with national guidance. Arrhythmia management including atrial fibrillation as well as the use of scoring systems as the CHADVASC score also commonly appears in the short-answer question (SAQ) paper, which is covered in this chapter in line with current NICE guidance. In addition, there is also a section on the diagnosis and differentiation on managing a patient with a transient loss of consciousness and the associated risk factors of sudden cardiac death. This chapter also includes sections on hypertensive emergencies and the management of heart failure.
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Visser, Frans, and Maarten Simoons. Percutaneous Coronary Intervention and Thrombolysis in AMI & other ACS. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199544769.003.0003.
Full textAbstract:
• Acute coronary syndromes (ACS) comprise an evolving acute myocardial infarction (AMI) presenting with or without ST-elevation and unstable angina• Patients presenting with an ST-elevation MI require immediate reperfusion therapy by primary percutaneous coronary intervention (PCI) or, if such is not available, thrombolysis• Cardiologists, emergency care physicians, general practictioners and ambulance services should collaborate to develop a national or regional system to optimise AMI therapy, given the national or local facilities and available resources• A subgroup of high-risk patients presenting with ACS without ST-elevation benefit from PCI or coronary artery bypass graft surgery• In all patients with ACS intensive anti-platelet and anti-thrombotic therapy is warranted, as well as B-blockers, ACE-inhibitors and statins.
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Macleod, Dr Donald C., Dr Ian Scott, Professor Calum Archibald Macrae, Dr Neal Uren, Dr Neil Grubb, Professor Derek Bell, Dr Mike Jones, et al. Cardiac diseases and resuscitation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199565979.003.0004.
Full textAbstract:
Chapter 4 discusses cardiac diseases and resuscitation, including symptoms, signs, and diagnostic investigations in cardiac disease, adult cardiopulmonary resuscitation, cardiovascular risk assessment, heart failure, acute coronary syndromes, arrhythmias, hypertension and hypertensive emergencies, thromboembolic disease, valvular disease, infective endocarditis, cardiomyopathies, congenital heart disease, heart disease in pregnancy, diseases of arteries and veins, rheumatic fever, pericarditis, ST segment elevation, and myocardial infarction.
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Wiffen, Philip, Marc Mitchell, Melanie Snelling, and Nicola Stoner. Therapy-related issues: cardiovascular system. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198735823.003.0016.
Full textAbstract:
This chapter is aimed at junior hospital pharmacists and community pharmacists and is loosely based on the British National Formulary, Chapter 2. It covers diagnosis, symptoms, and treatment management plans for a variety of cardiovascular topics including hypertension, heart failure, and angina, and additional topics that cover issues related to anticoagulation, acute coronary syndromes, ST-segment elevation myocardial infarction, and cardiopulmonary resuscitation.
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Nihoyannopoulos, Petros, and Fausto Pinto. Ischaemic heart disease. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199599639.003.0012.
Full textAbstract:
Echocardiography with its multiple modalities plays a central role in the evaluation of patients with known or suspected coronary artery disease, starting from the differential diagnosis of the patient presenting with acute chest pain. In the patient presenting with acute myocardial infarction (raised troponins) whether it is with ST-segment elevation or without, echocardiography is the first imaging modality used in order to ascertain the presence and extent of LV dysfunction and the presence of complications. In the absence of myocardial infarction (negative troponins), echocardiography will play an important diagnostic role in identifying the presence of reversible myocardial ischaemia. Stress echocardiography in many institutions is now the preferred stress modality associated with imaging as it is cost-effective and does not use ionizing radiation. Finally, echocardiography plays a pivotal role in the assessment of myocardial viability since the presence and extent of viable myocardium may guide therapeutic strategies. It has been stressed that laboratories and individuals need to have experience and be accredited by the authorities so that the results of echocardiographic investigations will be credible.
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Bell, Robert M. Pathophysiology of coronary syndromes. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0145.
Full textAbstract:
The pathophysiology of acute coronary syndromes is characterized by an acute mismatch of blood supply to the myocardium to meet the prevailing metabolic need. By far the commonest aetiology of myocardial ischaemia is coronary artery disease . An inflammatory process that evolves over the period of many decades, coronary artery disease is characterized by the deposition of cholesterol and cholesterol laden macrophages within the intima of the vessel wall. This process can be accelerated by a number of cardiovascular risk factors (smoking, hypertension, hyperlipidaemia, hypercholesterolaemia, diabetes), which can culminate in the formation of the unstable plaque responsible for the emergent presentation of ST-elevation myocardial infarction. This chapter reviews the prolonged inflammatory process responsible for atheroma formation, along with rarer, non-atheroma-related causes of acute coronary syndromes.
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Reffelmann, Thorsten, and Robert Kloner. Adjunctive Reperfusion Therapy Post-AMI. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199544769.003.0009.
Full textAbstract:
• Reperfusion of the occluded coronary artery in an ST-segment-elevation myocardial infarction is the most effective approach for reducing infarct size, preserving left ventricular ejection fraction, lowering the incidence and severity of congestive heart failure and improving prognosis• Hence, several pharmacologic agents intended to improve target vessel patency as an adjunct to thrombolysis or primary percutaneous coronary intervention have been shown to be beneficial in patients with reperfusion therapy for acute myocardial infarction, namely antiplatelet and anticoagulation agents• Animal investigations have suggested that coronary reperfusion may also result in undesirable cardiac alterations, termed ‘reperfusion injury’, such as reversible contractile dysfunction (‘stunning’), microvascular obstruction (‘no-reflow’), and in several studies the progression of myocardial necrosis (‘lethal reperfusion injury’)• Clinical investigations of various pharmacologic interventions as an adjunctive therapy to reperfusion to reduce final infarct size, the amount of contractile dysfunction and to improve prognosis have been mostly inconsistent; only a few interventions, e.g. adenosine and atrial natriuretic peptide seem to show promise at least in certain subgroups.
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Verheugt, Freek W. A. Fibrinolytic therapy. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198784906.003.0038.
Full textAbstract:
Fibrinolytic agents are able to reopen blood vessels that are occluded by a fresh thrombus. Urokinase, streptokinase, and streptokinase derivatives were the first effective agents. Recombinant plasminogen activators became available and they are specific for thrombus-bound fibrin. Significant bleeding is the major side effect of fibrinolysis, a major hurdle for its use. The current era of mechanical reperfusion has made fibrinolytic therapy a niche treatment for acute arterial thrombosis such as ST elevation myocardial infarction and stroke. Only for pulmonary embolism with haemodynamic consequences and mechanical heart valve thrombosis may lytic therapy have a place in selected patients.
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Capodanno, Davide. Bivalirudin and argatroban. Edited by Raffaele DeCaterina. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198784906.003.0052.
Full textAbstract:
The central role of thrombin in the process of clot formation makes it an important therapeutic target. Heparin is a potent anticoagulant, but has a number of limitations, in that—for example—it does not bind clot-bound thrombin, activates platelets, and may determine heparin-induced thrombocytopenia (HIT). Bivalirudin and argatroban, which belong to the class of intravenous direct thrombin inhibitors, overcome many of the limitations of heparin. Bivalirudin is currently indicated for patients undergoing percutaneous coronary intervention, patients with non-ST-segment elevation acute coronary syndromes planned for urgent or early intervention, and patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Both argatroban and bivalirudin can be used as an alternative to heparin in patients with HIT and HIT-thrombosis syndrome. This chapter describes the current clinical applications of bivalirudin and argatroban.
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Nahir, Menachem, Doron Zahger, and Yonathan Hasin. Recommendations for the structure, organization, and operation of intensive cardiac care units. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0010.
Full textAbstract:
Care for the critically ill cardiovascular patients and their families requires a unique environment that is structurally different from other clinical units. Coronary care units were introduced in the 1960s for the main purpose of prevention and prompt treatment of life-threatening cardiac arrhythmias related to acute myocardial infarction. Since then, major progress in cardiology in general and acute cardiac care, in particular, dictated a major change in the structure and organization of these units, symbolically expressed in the new title of ‘intensive cardiac care unit’. Contemporary intensive cardiac care units receive older and more complex patients, often with multiple comorbidities and diverse diagnoses. The modern intensive cardiac care unit incorporates sophisticated monitoring and up-to-date equipment to meet the changing needs of the patient with cardiovascular disease requiring critical care. The intensive cardiac care unit operates in the centre of the hospital’s cardiology service, receiving patients from the mobile care unit (directly or via an ST elevation myocardial infarction network), the emergency department, and other wards, including coronary, structural, and electrophysiology intervention laboratories and operating rooms. Patients are usually unstable and require immediate full attention by highly trained medical and nursing staff. The 2005 recommendations for the structure, organization, and operations of the intensive cardiac care unit were issued by Hasin et al. for the Working Group of Acute Cardiac Care of the European Society of Cardiology, which serves as basis for this chapter. The chapter will focus on the requirements for staffing, training, and accreditation, as well as the structure organization and equipment of the intensive and intermediate cardiac care units.