Scientific editor: Strokina OA, therapist, doctor of functional diagnostics. Practical experience since 2015.
October, 2018.
Myocardial infarction - this is the most severe clinical form coronary heart disease (CHD).
Myocardial infarction is characterized by necrosis (necrosis) of a portion of the heart muscle due to prolonged circulatory disorders (ischemia) in the myocardium. Most often develops in the left ventricle.
The heart is a muscular pump bag and plays a role in the body, driving blood. Oxygen to the heart muscle deliver large coronary vessels. If any blockage of the vessel by a thrombus, blood flow to the myocardium is terminated, blood is not supplied, so that the portion devoid of oxygen dies.
Within 30 minutes of the heart muscle is still viable, then the process of irreversible changes begin.
types of heart attacks
Depending on the size of focal necrosis distinguish macrofocal and small-focal myocardial infarction. Melkoochagovyj myocardial characterized by the absence of a pathological tooth Q (typical diagnostic criterion defined in the electrocardiogram).
The stages of development are the following periods:
- growing - 0-6 hours;
- acute - from 6 hours to 7 days;
- healing or scarring - from 7 to 28 days;
- healed - from 29 days.
Described division is very relative and is valuable more for descriptive and research purposes.
Adrift release:
- classic version - a disease with typical symptoms (pain, its character and localization)
- atypical - a different localization of pain or symptoms of heart attack;
- asthmatic embodiment (clinic cardiac asthma or pulmonary edema accompanied by severe dyspnea)
- abdominal (pain in the upper abdomen, nausea, vomiting, diarrhea),
- arrhythmic (manifested different types of heart rhythm disturbances)
- cerebrovascular (clinic, similar to ischemic attack)
- painless form (symptoms are either absent or very low).
Also can be a heart attack:
- recurrent - the appearance of new foci of necrosis up to 28 days
- recurrent myocardial infarction - the appearance of new foci of necrosis after 28 days from the previous heart attack.
Causes of
The main cause of myocardial infarction is atherosclerosis of the coronary arteries. It is also possible heart attack in violation of the blood clotting - coagulopathies. In addition, the disease may cause coronary vasospasm.
Predisposing factors of myocardial infarction:
- age (men over 45, women over 55 years old);
- gender (male myocardial infarction occurs 3-5 times more frequently than women);
- sedentary lifestyle (lack of exercise);
- heredity;
- alcohol abuse;
- smoking, including passive;
- obesity ;
- arterial hypertension ;
- diabetes ;
- previous myocardial infarction;
- mental lability and instability to stress;
- improper diet (high intake of animal fat).
myocardial infarction symptoms
The main symptom of the disease is the intense chest pain (anginal). The pain usually occurs in the night or early morning hours.
Pain lasts more than 20 minutes and stopped by only a few hours of drug preparations.
Important! Nitrates (nitroglycerin) in myocardial infarction ineffective.
Pain occur suddenly and are of a burning character ( "knife-like" pain or "stake through the chest"). In other cases, pain similar to angina - pain pressing, as though seized hoop or squeezed in a vise.
The pain radiates to the left arm, causing tingling and numbness in the wrist and fingers. Possible irradiation in the neck, shoulder, jaw, interscapular space.
Another characteristic is its wave-like pain, then it decreases, then increases.
Against the background of a pain attack, there is considerable pallor, copious cold sweat. The patient feels a sense of lack of air, pulse quickens. In addition, there is the fear of death.
In some cases, the only symptom of heart attack is sudden cardiac arrest.
Symptoms of atypical forms of myocardial infarction
The above symptoms does not occur in all cases of myocardial infarction. Sometimes there is an atypical course of the disease:
Abdominal. Proceeds as pancreatitis, and is characterized by pain in the epigastric region, hiccups, flatulence, nausea and vomiting. On palpation of the abdomen is determined by its painless, signs of peritoneal irritation are absent.
Asthmatic form. It reminds attack asthmaAppears and intensifies shortness of breath, there is a dry, nonproductive cough.
Arrhythmic form is made when dominated by various types of cardiac arrhythmias.
Silent (malosimptomno) form. Rare, more common in the elderly. Painless form is characteristic for patients with diabetes mellitus due to violations of sensitivity and shows weakness, sleep disturbance, depressed mood and a feeling of discomfort behind the breastbone.
Cerebral form. Myocardial infarction with cerebral form occurs in patients with a history of neurological history and occurs against a background of reduced or elevated blood pressure. Manifested by headache, dizziness, nausea, vomiting, blurred vision, pomrachneniem consciousness, and people of old age as a result of cerebral blood flow may develop psychoses.
Diagnostics
The diagnosis of myocardial infarction is crucial symptoms of the disease and the collection of stories, but in atypical forms of the fore instrumental and laboratory methods:
- General blood analysis. The blood is determined by leukocytosis, increased erythrocyte sedimentation rate;
- Determination of blood troponin T and I, CK-MB;
- Electrocardiogram (ECG) 12 lead. For classical myocardial infarction ECG changes are pathological tooth Q and ST segment elevation in at least two consecutive leads. An ideal variant is to compare the ECG during an attack with an electrocardiogram, that have been made previously, in the absence of any clinical picture. Unfortunately, some cardiac arrhythmias do not accurately diagnose a heart attack on the film. Therefore it is important and other methods of examination.
- Echocardiography (echocardiography). It helps to assess myocardial contractility and identify the area where cuts are weak, but echocardiography also can not give precise and unambiguous data the presence of a heart attack as a violation of contractility can be not only necrosis of heart tissue, but also in the lack of blood supply (ischemia).
- Coronary angiography reveals stenosis or blocked artery and a stent to hold it, if necessary.
- Magnetic resonance imaging (MRI) clearly reveals the center of the affected myocardium, it helps to differentiate ischemic and inflammatory nature of the disease.
First aid for heart attack
For suspected myocardial infarction patient must
- discontinue any exercise,
- provide fresh air (open window)
- facilitate breathing (open collar)
- help him to take a comfortable position (half-sitting or lying down with your head elevated)
- take nitroglycerin tablet under the tongue or 1 dose nitrospreya if within 5 minutes, no pain decreased, and nitroglycerin is well tolerated, it is necessary to take the pill again. If chest pain or discomfort does not disappear within 5 minutes after the re-taking nitroglycerin pills and if you normally work faster, you should immediately call the brigade SMP.
- also chew 250 mg of aspirin, i.e. ½ tablet (in such a drug will fall in blood) and in the presence of clopidogrel - 300 mg.
- in the absence of nitro-containing drugs can be used validol valokordin valoserdin or 40-50 drops.
- necessarily measure blood pressure
In the case of cardiac arrest and breathing immediately begin chest compressions and rescue breathing (respiration "mouth to mouth"). It has been proven that the effectiveness of cardiopulmonary resuscitation depends more on maintaining the blood circulation, than from breathing, so it is necessary to begin with the compressions on the sternum rate of about 100 per minute. If there is a sick man 1 recommended resuscitation in a ratio of 30 compressions to 2 breaths. 2 If a person is 15 to 1.
Treatment
Treatment of the patient with myocardial infarction resuscitator performed in the ICU or in a specialized cardiologist office (infarcted). Therapy in this disease has the following objectives:
- stop pain;
- limit the spread of necrosis;
- restore coronary blood flow;
- preventing early complications.
These objectives are achieved by a complex but clear organization of the SMP and Vascular Center. The first step is to restore blood flow in the coronary arteries. For this purpose, depending on the time interval:
- Percutaneous intervention - balloon angioplasty and stenting (lumen recovery vessel by inflating the balloon and special formulation of the carcass at this point);
- Coronary bypass surgery (restoration of blood flow using prosthesis or other artery to bypass the occluded portion of the vessel);
- Thrombolytic therapy - intravenous drugs to dissolve blood clots.
Surgical techniques are used only after a coronary angiography to be done absolutely all patients with suspected myocardial infarction.
Thrombolytics selected at impossibility of surgical treatment in the next 90 minutes.
In addition to the therapy to restore blood flow by vascular lesions, to treat the following groups of drugs are used:
- Narcotic analgesics (morphine, promedol) for anesthesia and sedation of the patient,
- oxygen inhalation,
- Antithrombotic drugs (clopidogrel + aspirin) and anticoagulants (heparin intravenous, fraksiparin in the acute phase of the process or oral Pradaksa, Brilinta in a later phase of the disease) to prevent re-thrombosis coronary arteries,
- ACE inhibitors (captopril, zofenopril) or Sartai (valsartan) to improve the prognosis,
- Beta blockers (metoprolol, propranolol, atenolol) for deceleration of heart rate and reduce the likelihood of repeated or recurrent myocardial appearance and life-threatening arrhythmias,
- Statins (atorvastatin, simvastatin) in high doses.
The patient creates a complete physical and mental rest. Bed rest zavisimotsi assigned to the severity of the patient, generally it takes 24 hours or more due to the prevention of thrombosis.
Treatment in hospital lasts 21-28 days on average, after which the patient undergoing rehabilitation on an outpatient basis. Patients who have had a myocardial infarction, it is recommended diet with restriction of fats and carbohydrates, but rich in fresh fruit and vegetables, is assigned to aspirin (for life), statins, anticoagulants and other perparatov improving prognosis.
Patients who are overweight need to reset it. Also shown regular moderate and low intensity physical load for at least 30 minutes 5 times a week (walking and therapeutic exercise).
The prognosis of myocardial infarction depends on how quickly the treatment is started, the size of necrosis, focal location, severity of the disease.
Complications after heart attack
Complications of myocardial infarction are divided into early and late. Early complications develop during the acute phase of the disease and cause high mortality.
The early complications include:
- acute circulatory failure (heart attack, cardiogenic shock, arrhythmogenic shock, pulmonary edema);
- violation of rhythm and conduction (atrial fibrillation, premature beats, ventricular fibrillation);
- acute cardiac aneurysm;
- thromboembolic complications.
Late complications of myocardial infarction:
- thromboembolism;
- post-infarction syndrome;
- chronic heart failure;
- cardiac aneurysm.
prevention
- full cessation of smoking and alcohol;
- a diet rich in potassium;
- weight normalization;
- regular exercise;
- blood pressure control, and blood cholesterol
- treatment of diabetes.
sources:
- Acute myocardial infarction with ST elevation electrocardiogram segment. - Federal clinical guidelines 2016.
- E.V.Shlyahto, A.Sh.Revishvili. All Russian clinical recommendations Control risk of sudden cardiac arrest and sudden cardiac death, prevention and first aid. - Herald arrhythmology, №89, 2017.
