A patient presents with intense chest pain of 2 hrs duration. ECG shows ST depression in leads I and V1 to V4 There is associated T inversion and CPK-MB is elevated. Which of the following should be included in his management-
Correct Answer: Nitroglycerine drip
Description: Ref: R Alagappan - Manual of Practical Medicine 4th Edition.pg no:188-190 Management 1. Bed-rest 2. Nasal O2 3. Morphine given in an intravenous form (< 1 mg per minute) to a maximum dose of 10-15 mg. It acts as a pulmonary venodilator and also as an analgesic to allete anxiety 4. Nitrates may be given sublingually for rapid action of relief of pain by coronary vasodilation. It also helps to reduce the preload of the hea, being a predominant venodilator. If pain persists after administration of sublingual nitrates, IV infusion of nitroglycerine may be given, provided the systolic BP is maintained above 100 mm Hg 5. Aspirin is given orally in the dose ranging from 100 to 300 mg 6. Thrombolytic therapy (Streptokinase, Urokinase, Tissue plasminogen activator) may be given and is paicularly useful if given within 6 hrs of onset ofsymptoms, but may be given upto 12 hrs after onset of symptoms. Ideal--door to needle time 30 min. Thrombolytic agents for Myocardial Infarction Agents with fibrin specificity: 1. Alteplase (-PA) 15 mg IV bolus followed by 0.75 mg/kg IV infusion (upto 50 mg) over 30 minutes then 0.5 mg/kg (upto 35 mg) by IV infusion over 60 minutes (maximum dose 100 mg IV over 90 minutes) 2. Reteplase (r-PA) 10 mg IV bolus over 2 minutes followed by another 10 mg IV bolus after 30 minutes. 3. Tenecteplase (TNK-tPA) 0.5 mg/kg IV bolus (<60 kg-30 mg, 61-70 kg -35 mg, 71-80 kg-40 mg, 81-90 kg- 45 mg, >90 kg-50 mg) Agents without fibrin specificity: 1. Streptokinase - 1.5 million units IV infusion over 60 minutes 2. Urokinase Because of the development of antibodies, patients who were previously treated with streptokinase should be given an alternate thrombolytic agent.Beta blockers can be used in LV dysfunction with low ejection fraction whereas calcium channel blockers should not be used. ACE inhibitor is the ideal choice in the presence of LV dysfunction and cardiac failure with normal renal function. 7. Heparin may be given in a dose of 5000 U, 12 hourly, subcutaneously, as prophylaxis against development of deep vein thrombosis and 12,500 U, 12 hourly, subcutaneously, as prophylaxis against development of mural thrombus or extension of the coronary thrombus, for a period of 7-10 days 8. b-blockers are staed immediately, or after two weeks and given for a minimum duration of two years, if there is no contraindication for their use,as these agents (atenolol, metoprolol, propranolol) help in reducing morbidity and moality significantly. b-blockers can be given even if the ejection fraction as determined by Echo is < 40%, but calcium channel blockers must be avoided 9. ACE inhibitors help in cardiac remodelling and reduce morbidity and moality 10. Treatment of the associated complications as and when they arise 11. Advice patient to stop smoking 12. Control of associated risk factors (systemic hypeension, diabetes mellitus, hyperlipidaemia) 13. Rehabilitation If the patient is stable and no complications: Sit in a chair - 2nd day Walk to toilet - 3rd day Return home - 7th day Back to work - 6th week Driving (LMV) - 6 weeks Intercourse - 8 weeks Air travel - 8 weeks 14. Surgery (coronary angioplasty, coronary aery bypass grafting) if medical management fails or if there is severe compromise of coronary circulation. 15. Drug eluting stents - Many drugs have been considered for drug eluting stents. The main drugs used are paclitaxel (Taxol), sirolimus and their derivatives (tacrolimus, everolimus). These stents have lower rates of restenosis. They act by inhibiting neointimal hyperplasia (antiproliferative action). 16. Assessment of ischaemic burden: A sub-maximal stress testing is done at the end of first week and a maximal exercise stress test at the end of 6 weeks. Stress testing aids in assessing the patient's ischaemic burden and planning fuher line of management. 17. Alternate therapies: * Transmyocardial laser revascularisation by percutaneous technique * Enhanced external counterpulsation to decrease the frequency of angina * Spinal cord stimulation ( C7-T1 - epidural space electrode) to improve anginal symptoms
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