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Optimal Management of the Post Myocardial Infarction Patient. Prognosis Post MI. Mortality in the first year post MI averages 10% Subsequently mortality 5% per year 85% of deaths due to CAD 50% of these sudden 50% within first 3 months 33% within the first three weeks. b -Block.

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optimal management of the post myocardial infarction patient

Optimal Managementof thePost Myocardial InfarctionPatient

Continuing Medical Implementation …...bridging the care gap

prognosis post mi
Prognosis Post MI
  • Mortality in the first year post MI averages 10%
  • Subsequently mortality 5% per year
  • 85% of deaths due to CAD
    • 50% of these sudden
    • 50% within first 3 months
    • 33% within the first three weeks

Continuing Medical Implementation …...bridging the care gap

early mortality after ami

b-Block

ASSENT-2

CCU

GUSTO

GUSTO-3

GISSI-1

Pre-CCU

ISIS-2

Early Mortality After AMI

Mortality at 25 - 30 Days

SK

SK+ASA

tPA

tPA &

rPA

tPA &

TNK

Continuing Medical Implementation …...bridging the care gap

risk stratification
Risk Stratification
  • Historical
  • Clinical
  • ECG
  • Lab
  • Non-Invasive Testing
    • LV function LVEF < 40 %
    • Residual ischaemia
  • Invasive Testing
    • Cardiac Catheterization
    • EPS

Continuing Medical Implementation …...bridging the care gap

lv function determines prognosis
LV Function Determines Prognosis

Continuing Medical Implementation …...bridging the care gap

acute phase risk stratification pre infarction characteristics
Age > 70

Prior myocardial infarction

Female gender

Hypertension

History of CHF

Hyperlipidemia

Diabetes

Race

Clinical Criteria

ECG Criteria

Chest x-ray-cardiomegaly

Markedly elevated cardiac enzymes

Elevated BUN

Hemodynamic Criteria

Complications

VSD/PMD-rupture

Myocardial rupture

Acute Phase Risk Stratification: Pre-infarction characteristics

Continuing Medical Implementation …...bridging the care gap

acute mortality reduction
Acute Mortality Reduction
  • Early Recognition of Symptoms
  • Pre -Hospital Resuscitation of Sudden Death
  • Fast-Track Protocol for Thrombolytic Therapy
  • Code STEMI – Direct PCI protocols
  • Optimal Use of Adjunctive Therapy
  • Monitoring for Complications
  • Evidence Based Risk Stratification
  • Appropriate Revascularization for NSTEMI

Continuing Medical Implementation …...bridging the care gap

acute phase risk stratification physical examination
Acute Phase Risk Stratification:Physical Examination
  • Clinical assessment of LV dysfunction
    • No history of CHF
    • No CHF with index MI
    • No LBBB, pacemaker or LVH with ST-T’s
    • Absence of Q waves-site of MI or outside index territory
    • 91 % predictive value of EF  40%
  • Killip classification
  • Hemodynamic classification
  • Mechanical complications

Continuing Medical Implementation …...bridging the care gap

clinical signs of lv dysfunction
Hypotension

Pulsus alternans

Reduced volume carotid

LV apical enlargement/displacement

Sustained apex - to S2

Soft S1

Paradoxically split S2

S3 gallop

(not S4 = impaired LV compliance)

Mitral regurgitation

Pulmonary congestion

rales

Clinical Signs of LV Dysfunction

Continuing Medical Implementation …...bridging the care gap

acute phase risk stratification importance of lv dysfunction
Acute Phase Risk Stratification:Importance of LV dysfunction

Continuing Medical Implementation …...bridging the care gap

acute phase risk stratification importance of lv dysfunction1
Acute Phase Risk Stratification:Importance of LV dysfunction

Continuing Medical Implementation …...bridging the care gap

determinants of prognosis
Timing of revascularization

Size of MI

Extent of LV dysfunction

Extent of CAD

Recurrent ischaemia

Mechanical complications

Mitral regurgitation

VSD

Aneurysm

Rupture

Determinants of Prognosis

Continuing Medical Implementation …...bridging the care gap

acute phase risk stratification electrocardiographic features
Acute Phase Risk Stratification:Electrocardiographic features
  • Anterior MI/ Persisting ST elevation
  • Q waves in multiple leads
  • Non - Q MI
  • LVH
  • Reciprocal ( anterior ) ST depression
  • Persisting ST depression
  • Prolonged QT
  • Conduction defects/ heart block
  • Sinus tachycardia/atrial fibrillation

Continuing Medical Implementation …...bridging the care gap

impact of conduction disturbances on prognosis
Impact of Conduction Disturbances on Prognosis

Continuing Medical Implementation …...bridging the care gap

slide18
Post MI Management-PhasesNB: Phases compressed and abbreviated with early invasive strategies and direct PCI
  • Acute Evaluation Phase
  • CCU Phase
  • Hospital Phase
  • Pre-discharge Phase
  • Convalescence
  • Long Term Management
    • Secondary prevention critical to preserve acute mortality benefits

Brief duration leaves little time for comprehension and education

Continuing Medical Implementation …...bridging the care gap

post mi management phases
Acute Evaluation Phase

ASA

Plavix (NSTEMI/PCI)

Glycoprotein IIB/IIIA inhibitors

Heparin, LMWH

Thrombolytics (STEMI,LBBB)

Direct PCI

IV -blocker

IV NTG

Complication Surveillance

CHF

Pericarditis

Recurrent ischaemia

Mechanical complication

ventricular septal rupture

papillary muscle dysfunction or tear

LV thrombus

Post MI Management-Phases

Continuing Medical Implementation …...bridging the care gap

role of echocardiography
Role of Echocardiography
  • LV function
  • Complications of MI
    • Thrombus
    • Aneurysm
    • Papillary muscle rupture/dysfunction
    • Septal rupture
    • Free wall rupture

Continuing Medical Implementation …...bridging the care gap

post mi management phases1
Post CCU- Early ambulation

ASA

-blocker

ACE- inhibitor

Lipid lowering

usually statin

Anti-coagulation

Atrial fib/DVT/CHF/LVT

Telemetry for arrhythmia

Echo for LV function/thrombus

Patient education & counseling

dietary

risk factors

further Ix

Screening for complications

Risk stratification

Post MI Management-Phases

Continuing Medical Implementation …...bridging the care gap

guide for cardiac rehab and prevention
Guide for Cardiac Rehab and Prevention
  • Self contained
  • Comprehensive
  • Downloadable
  • Printable
  • Customizable
  • See “Cardiac Rehab” button on website www.cvtoolbox.com

Continuing Medical Implementation …...bridging the care gap

cardiovascular risk reduction cocktail for 2 prevention
Cardiovascular Risk Reduction Cocktail for 2 Prevention
  • ASA (Plavix post ACS/PCI)
  • Lipid Targets
    • TC4.5, TG1.7, HDL1.2, LDL2.0 (1.8) TC/HDL  4 (3)
  • ACE inhibitor
    • Ramipril 2.510 mg
    • Perindopril 28 mg
    • Trandolapril 14 mg
  • Beta-blocker for post- MI or LV dysfunction

Continuing Medical Implementation …...bridging the care gap

potential cumulative impact of 2 prevention treatments
Potential Cumulative Impact of 2° Prevention Treatments

CUMULATIVE BENEFITS ARE LIKELY TO BE IN EXCESS OF

78% RRR, WHICH IS SUBSTANTIAL

Continuing Medical Implementation …...bridging the care gap

Adapted from Yusuf, S. Two decades of progress in preventing vascular disease. Lancet 2002; 360: 2-3.

at what level can we have the greatest impact
At what level can we have the greatest impact?

Interventions-Revascularization-Devices-Procedures

Specialist/Cardiologist-Invasive Dx/Tx-Monitoring/Rehab/Reinforcement

2º & 3º

Risk Stratification-Rx Optimization/ Adherence-FD & Specialist

1º & 2º

Recognition-Screening-Initial Therapy- Family MD

Primary Care Physician

Community Based Awareness/Understanding

Prevention Awareness Programs/PHN

Continuing Medical Implementation …...bridging the care gap

post mi management pre discharge tmt
Post MI Management:Pre-discharge TMT
  • Value of pre-discharge stress test
    • useful to identify those at risk for an early event

( UAP, recurrent MI, arrhythmia, sudden death)

    • low level < 6 METS, 70 % MPHR or symptom limited
  • Predictors of poor outcome
    • ischaemic ST depression > 1 mm is inconsistent predictor of mortality
    • poor exercise tolerance < 3 minutes doubles 1 year mortality ( 7% to14%)
    • inability to exercise or contra-indication to TMT identifies High Risk patient.

Continuing Medical Implementation …...bridging the care gap

post mi management phases convalescence
Post MI Management-Phases:Convalescence

At time of discharge patient should be on:

  • ASA unless contra-indication
  • Plavix if PCI/NSTEMI (duration minimum1 year)
    • Longer duration of Plavix if DES in critical location or complex lesion
  • -blocker unless contra-indication
  • Ace inhibitor for CHF or LV dysfunction
    • All for vascular protection?
  • Statin for LDL to < 2.0 mmol/L (minimum 50% reduction)

Continuing Medical Implementation …...bridging the care gap

post mi management phases convalescence1
Post MI Management-Phases:Convalescence

Late Risk Stratification - 4 to 8 weeks

(Assessment of residual ischaemia)

  • TMT
  • Stress Nuclear Perfusion Study
    • uninterpretable ECG
    • Equivocal TMT
  • Persantine Nuclear Perfusion Study
    • inability to exercise
    • LBBB
    • NB!!! Contra-indicated in asthma

Continuing Medical Implementation …...bridging the care gap

slide29
High Risk

extensive ECG changes

anterior/ infero-posterior/ prior MI

Prior MI

Residual ischaemia

post MI angina

positive TMT/ perfusion scan

non-Q MI

ischaemia at a distance

Complicated MI

CHF/ flash pulmonary edema

shock

heart block

RBBB

sustained ventricular arrhythmias

Anxiety/ physical labor/ young age

Indications for AngiographyNB: In interventional environment many patients undergo early angiography

Continuing Medical Implementation …...bridging the care gap

http www timi org
http://www.timi.org/

Continuing Medical Implementation …...bridging the care gap

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