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Course Title: Clinical Pharmacy-II

Lecture No: Z-16
Topic:Myocardial Infarction Investigation &
Treatment
Ms. Anum Hanif
Lecturer
Faculty of Pharmacy
Hajvery University (HU)
 Learning Outcomes
Students will learn in this lecture about:
•How to investigate Myocardial Infarction
•General Measures
•Treatment
•Complications
•Follow up
Investigations:
• According to the WHO criteria myocardial
infarction can be diagnosed, if two of the
following factors are present:
• A history of ischemic type chest pain.
• ECG changes of myocardial infarction.
• Initially a rise and then fall of cardiac
Enzymes.
ECG:
• The classical evolution of ECG changes is
myocardial infarction are:
• Peaks (hyper-acute) T waves →ST segment
elevation→ formation of Q waves →T wave
inversion.
• These changes may occur over a few hour to
several days.
•Occasionally initial ECG is normal and
diagnostic changes appear a few hour later,
therefore serial ECGs increase the yield of
diagnosis.
•Interpretation of EGC become difficult when
there is a bundle branch block or previous
myocardial infarction.
 Cardiac enzyme:
• Myocardial infarction leads to detectable rise
in the plasma concentration of the
enzymes normally confined within cardiac cells.
•The enzymes most widely used in the detection
of myocardial infarction are following:
 Cardiac specific troponins
Troponin T and troponin I:
• These enzymes are highly specific to cardiac
injury and can detect small infarctions that are
below the detection limit for CK-MB.
•Troponin T and I rise early (within 2-4 hours)
and remained elevated.
• Troponin I, 7-10 days.
• Troponin T, 10-14 days.
• Therefore these enzymes are specially helpful
if a patient comes 2-3 days after infarction
because CK-MB returns to normal till that time
while these enzymes remain elevated.
•Although LDH is also elevated for 10 days but it
is non specific and is also elevated in other
conditions.
• Troponin T kits are available in the market and
this test can be performed at the bed side .
•This is now most widely used test for cardiac
marker.
Creatine Kinase (CK)
• It rises within 4-8 hours, peaks at 24 hour and
generally return to normal by 2-3 days.
• Creatine kinase has three iso-enzymes
• CK-MB----present in heart.
• CK-MM----present in skeletal muscles and
heart.
• CK-BB-----present in brain.
 Echocardioagraphy:
•Echocardioagraphy provides convenient bedside
assessment of left ventricular global and regional
function.
•This may be helpful in diagnosis and
management of infarction.
Other Serum Markers:
• Aspartate aminotransferase(AST)
• Lactate dehydrogenase(LDH)
• Blood CP/ ERS
• X-ray chest
• Echocardiography
• Radionuclide scan
Management:
• All patients with suspected myocardial infarction
should be confines to strict bed rest and admitted
in hospital preferably in ICU.
General Measures:
1. An I/V cannula is inserted for emergency
medication.
2. Morphine 4-8 mg I/V + cyclizine 50 mg I/V to
relieve pain.
3. Oral aspirin (300 mg) one tablet chewable.
4. Nitroglycerin (Angised) sublingually if blood
pressure is stable.
5. Oxygen if saturation is low.
6. Intravenous beta blockers (Lopressor 5 mg ) if
tachycardia.
7. Thrombolytic streptokinase 1.5 million units
over 1 hour.
8.Acute angioplasty (primary percutaneous
intervention PCI) if thrombolytic therapy is
contraindicated.
9. Isosorbide dinitrate or nitroglycerin for 24-48
hours to relieve persistent pain if blood pressure is
stable.
10. For anxiety use medicine such as Alprazolam
(Xanax 0.5mg).
11. Bed rest for first 24-48 hours with bedside
commode facility. Smoking should not be
allowed.
Complications:
• Arrythmias.
• Murmur of venticular septal defect.
• Mitral regurgitation.
• Pericardial rub.
Follow up treatment and secondary
prevention:
• Initially Ambulation limited to home.
• No heavy lifting weights.
• Stop smoking.
• Reduce weight.
• Control blood pressure.
• Gradually increased activity, cardiac
rehabilitation and exercise training after 4-8
weeks.
• Sub maximal ETT or persantin thallium scan
before discharge (after 3-5 days of
uncomplicated MI).
• Returning to work after 6-8 weeks.
• Strict sugar control in diabetics.
• LDL cholesterol should be lowered below
100mg/dl with lipid lowering drugs such as
statins (simvastatins, atrovastatin).
• Aspirin continue indefinitely. Beta blocker has
been shown to reduce the incidence of death in
six months following an acute myocardial
infarction.
• One of the beta blockers e.g. Metoprolol 50mg
twice daily. Atenolol 100 mg once daily
• ACE inhibitors: prevent progressive left
ventricular dilation and dysfunction.
• Air travel: air travel should be avoided for 3
weeks after MI even the patient is
asymptomatic.
 Summary
Students have learnt about the:
•How to investigate Myocardial Infarction
•General Measures
•Treatment
•Complications
•Follow up
1. Students you can ask any
question regarding this
lecture.
2. Google Classroom discussion
board.