Transcript «Боль в грудной клетке. ИБС: инфаркт миокарда. Диагностика

"The pain in the chest.
ISCHEMIC HEART DISEASE:
myocardial infarction. Diagnosis,
differential diagnosis and
emergency treatment.
Lecturer: Prof. M. Rustamova
Myocardial infarction-acute disease caused by the
development of one or more lesions of ischemic
necrosis in cardiac muscle, various cardiac
disorders and clinical syndromes, as determined
by the nature of Reflex reactions related to acute
ischemia and myocardial necrosis.
ECG – SIGNS CHARACTERISTIC OF
MYOCARDIAL INFARCTION.
• Transmural myocardial infarction (within
the first few hours):
• enhancement (dome-shaped) ST segment
on izolin high, positive as well as pointed
tooth of t in some areas;
• reduction of ST segment contours below in
other areas;
ECG – SIGNS CHARACTERISTIC OF
MYOCARDIAL INFARCTION.
• Diskordant ST-segment change in various
areas;
• reduced amplitude R, deformation of
micro;
• the appearance of pathological zubza Q >
0.04 with wide and depth > 1/4 R;
ECG – SIGNS CHARACTERISTIC OF
MYOCARDIAL INFARCTION.
• within 2-3 days of gradual emergence
zubza QS;
• ST segment change and the appearance
of deep negative prongs t.
Subèndokardial myocardial
infarction:
• reduction of ST segment contours below;
• the appearance of deep negative prongs t;
• There may be all kinds of arrhythmias and
blockades.
.
AMI 2 x a week ago. Heart of the 76-year-old man. Clearly
visible demarcation line
Reproduced by kind permission of Drs McLay & Johnson - Tulane School of Medicine
Массивное поражение септы, давность ОИМ 1 неделя.
Reproduced by kind permission of Drs McLay & Johnson -Tulane School of Medicine
Nekrotič-rezorbtive syndrome:
• increased Myoglobin in the first 2-3 hours
and up to 1-2 h;
• improvement of MW-FSC in the first 4-8
hours and up to 2-3 days;
• enhancing the overall CPK in the first 4-8
hours and up to 3-4 days;
• increase LDH and LDG1 in the first 8-12
hours and up to 8-14 d;
Nekrotič-rezorbtive syndrome:
• increased AST in the first 8-12 hours and
up to 3-4 days;
• increase in body temperature during the
first 12 h;
• Leukocytosis within the first 2-6 hours and
up to 2-3 days;
• acceleration of SEDIMENTATION RATE
via 2-3 day with normalization depending
on the clinical course of the disease.
CLINICAL VARIANTS OF
MYOCARDIAL INFARCTION
Pain (status anginozus) is the most common and
characteristic version. The pain is localized to
the breast bone, heart, right from the belly, on
the entire surface of the thorax. Usually pain
oppressive, compact nature, rarer – pulse,
burning, cutting or undefined. The pain
continues for more than 20-30 min, often
several hours and often 1-2 m, can be
recurrent. It is administered by nitroglycerin or
Department include dinitrate, analgesics.
Asthmatic.
The clinical picture is shortness of breath,
a feeling of lack of air, choking. After
cupping levojeludockova failure patient
tells that the disease started with pain
behind the breastbone or in the heart,
but very quickly became short of breath.
Most often occurs when the heart muscle
papillary ones.
• Abdominal (gastral′gičeskij).
Pain manifests itself under mečevidnym or
in the process of the upper divisions of
diarrhoeal disorders èpigastriâ (nausea,
belching, hiccups, vomiting).
Aritmic.
Starts with the attack of ventricular
tachycardia, supraventricular, AV blockade
II extent or dire the blockade of
atrioventricular-ventricular feet beam
(beam Guisa).
• Cerebral infarction.
Is rare (in 0.8% of patients). The clinical
picture is dominated by symptoms of
cerebral circulation: fainting, dizziness,
nausea, vomiting, focal neurologic
symptoms. Chest pain is poorly expressed
or even absent.
• asymptomatic myocardial infarction
manifesting bouts have pains, transient
bouts of shortness of breath and other
short-lived changes in health. ECG is
crucial-a study in Dynamics.
COMPLICATIONS OF
MYOCARDIAL INFARCTION
• Cardiac arihythmia;
• acute circulatory failure (pulmonary edema,
cardiogen shock);
• tears of the heart;
• acute cardiac aneurysm;
• Èpistenokardičesk pericarditis;
• tromboèndokardit;
• thromboembolism;
COMPLICATIONS OF
MYOCARDIAL INFARCTION
• violations of the gastrointestinal tract
(stomach, bowel paresis, acute ulcers,
erosion of the stomach and intestines,
sometimes with the development of acute
bleeding);
• urinary system disorders (retention);
• postinfarction autoimmune syndrome Dresslera;
• syndrome of the anterior wall of the thorax,
shoulder syndrome;
• personality disorders (varying degrees of
symptoms, bleeding episodes sputannogo of
consciousness, hallucinations, delusional
disorders, konfabulâtorno-neurotic reactions,
fears and phobias, hypochondriacal reaction
reactive depression).
TREATMENT OF MYOCARDIAL
INFARCTION
Main tasks of the doctor are:
• mild pain attack;
• attempting to restore coronary blood flow
occlusion on the spot;
• warning of life-threatening arrhythmias;
• restriction zone infarction;
• treatment of complications;
• psychological and physical rehabilitation
TREATMENT OF MYOCARDIAL
INFARCTION
• THROMBOLYTIC
• ANTICOAGULANT
• AND ANTIAGREGANT THERAPY
TREATMENT OF MYOCARDIAL
INFARCTION
• Lysis therapy is carried out in the first 12 (but
more effectively it in the first 0.5 seconds from
start anginal′nogo -2 status) using performance
(intravenous) and vnutrikoronarnogo of
trombolitika. Thrombolysis is not shown if the
elevation is missing and the ECG ST segment
changes represented only ST depression or
missing altogether.
PROGRAM STATUS ANGINAL′NOGO EDEMA
• pain medicine administered subcutaneously or
intravenously,
• especially people aged patients, low supply.
• The introduction sequence is listed below.
• Each subsequent introduction means
inefficiency.
Baral′gin
5 ml5 or
solution of
Analgin
2 2ml
of
Баральгин
мл50%
или анальгин
50%
раствор
мл,
1% solution,
diphenhydramine
ml in/in
димедрол
1% раствор 1-2 1-2
мл в/в
Promedol
1-2% solution 1 ml in/in
Промедол 1-2% раствор 1 мл в/в
Papaveretum 1-2%
Омнопон
1-2%1раствор
solution
ml in/in1 мл в/в
Morphine
1%
Морфин
1%solution
раствор11 ml
мл in/in
в/в
For system and fibrinolysis intralumincoronari
apply the following preparations:
• streptokinase-1000000-1500000 IU dissolved in
100-150 ml of isotonic sodium chloride solution
and give/drip 250000 IU within 30 min, followed
by maintenance dose.
• To prevent possible allergic reactions previously
injected 30 mg prednisolone/in or
• streptodekaza-300 000FE (fibrinoliticakih
units) in 20-30 ml izotoniceski solution of
sodium chloride in/on for 10-15 min
(diagnostic test). If the behavior does not
occur within an hour, impose adverse
reactions/2700000 speeds-600000
300000 FE/min, or
• After fibrinolytic and anticoagulant therapy is prescribed
antiplatelet agents that patients myocardial infarction are
long-term, for 1 year or more:
• acetil′salicilovuû acid – 125 – 300 mg inwards 1 time per
day (inogd day) and dipyridamole on 50-75 mg 3 x/day
inwards (medication often prescribed in combination with
acetilsaliciovoj acid to strengthen antiagregantnogo
effect), or
• tiklopedin on 125-250 mg 1 -2 times a day and
sometimes every other day.
• urokinazu-4400 u/kg/in for 10 min, and then at
the dose of 4400 u/kg every hour it was
answered 10-12 h and 72 h, or rarely
• fibrinolizin – 80000-100000 IU/in the dissolved in
izotonicescom solution of sodium chloride at the
rate of 100 – 160 UNITS in 1 ml, the initial speed
of 10-12 drops per 1 minute (the drug
significantly favour the first three), or tissue
plasminogen activator (actilyse, al′teplaza).
Rehabilitation
• In determining the pace of rehabilitation include the
following symptoms:
• -prevalence of myocardial infarction:
• finely-, krupnoočagovyj, subèndokardial′nyj, circular;
• -the gravity of complications:
• arrhythmias, circulatory insufficiency, etc.;
• -age;
• -presence of heavy pathologies of internal organs:
• HYPERTENSION, diabetes, heart diseases, etc.
The stages of rehabilitation
• Phase I Begins after cupping anginoznogo
status and severe complications. The
patient performs statistical breathing
exercises, and exercises for small
medium-sized muscular arms, legs.
Includes massage of the legs, the
elements of autogenic training.
The stages of rehabilitation
• Phase II. Mode of bed rest, but with the
increasing volume of exercise. Complex
medical gymnastics is usually included
with the 2-day phase.
The stages of rehabilitation
• Stage III. Polupostel′nyj mode. Permitted
to sit on the bed with downy sometimes
feet on day 3, use the bedside Chair on
the 4th day. Complex medical gymnastics
continues.
The stages of rehabilitation
• Stage IV. Treatment Chamber. First
movement is permitted near the bed to the
7th day, and then by the House. Walking
in the House, staying in the self-servicing
Chair. On 8-9th day out into the corridor,
into the toilet.
The stages of rehabilitation
• Phase v. development of a common regime in
the Department. Dosed walking into Office, food
service, lifting on 6-12-speed ladders, morning
physical exercises. The samples measured
physical activity on 11-21-day myocardial
infarction in the absence of the following contraindications:
• -heart failure;
• -heart rhythm disorders;
• -other serious complications.
Prevention of CHD and AMI.
• Control of hyperlipidaemia is one of the
areas of the prevention of CHD; It begins
long before the appearance of clinical
symptoms of this pathology. Treatment
and prevention of Hyperlipidemia have
given the patient's age, cholesterol and
other factors.
• Phase VI. The increase in household
loads. Development of routes on flat and
rough ground. Continuation training on the
stairs (2-6 bays), workout at the gym
(subporogovyj), the complex of
physiotherapy exercises. Translation in
cardiological sanatorium
Hypo lipidic diet and prevention of risk
factors for CHD.
• Nežirne meats (beef, poultry, lean pork is rare);
• Fish (sel′d, sardine, cod, Pollock, icy, Pike, salmon, tuna, rare
CARP);
• Fresh vegetables and fruits are apples, citrus fruits, carrots,
beetroot, lettuces, herbs (cilantro, dill, parsley, etc.), cucumbers,
dried fruit as additives to tea and coffee;
• All varieties of vegetable oil, soft margarine varieties, occasionally a
small amount of butter;
• A small number of eggs (preferably white);
• Occasionally (during holidays) a small amount of sweet and baked
meals, including ice cream.
• Thank you for your attention