logging in or signing up myocardial infarction drjawed1974 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 578 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: January 27, 2011 This Presentation is Public Favorites: 0 Presentation Description ACUTE INFERIOR MYOCARDIAL INFARCTION WITH RIGHT VENTRICULAR EXTENSION, Comments Posting comment... By: ahmedhafez2030 (13 month(s) ago) بارك الله فيكم ونفع بكم رائع جدا Saving..... Post Reply Close Saving..... Edit Comment Close By: ahmedhafez2030 (13 month(s) ago) بارك الله فيكم ونفع بكم رائع جدا Saving..... Post Reply Close Saving..... 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JAWED Age: 55 yearsSex: FemaleOccupation : House wifeAddress: al hassa : Age: 55 yearsSex: FemaleOccupation : House wifeAddress: al hassa Presenting complain : Presenting complain Chest Pain since 05 days History of present illness : History of present illness 50 years old Saudi female presented in Emergency room with history of retro sternal chest pain since 05 days, initially mild and intermittent occur on rest as well as on exertion remain for about 5 minutes then relieved spontaneously without any medication. History of present illness : History of present illness She didn't consult to any doctor during these 5 days, until on day of admission when pain was severe diffuse all over the chest, continuous for 30 minutes, like burning sensation, radiating to left shoulder, associated with sweating and shortness of breath. Pain not relieved by rest, Pain not increase by inspiration or changing in position, no palpitation, no history of fever, no history of fall down or any trauma. She went to near by clinic where she was given symptomatic treatment and referred to KFHH : Pain not relieved by rest, Pain not increase by inspiration or changing in position, no palpitation, no history of fever, no history of fall down or any trauma. She went to near by clinic where she was given symptomatic treatment and referred to KFHH Review of systems : Review of systems General: No loss of weight No malaise or weakness No sleep disturbance GIT: No abdominal pain or vomiting No Diarrhea or constipation No hemetamesis or malena Slide 8: Respiratory system: No difficulty in breathing No coughGenito urinary: No burning micturation No haematuriaCNS: No epilepsy No paralysis PAST HISTORY : PAST HISTORY No history of diabetes No history of hypertension No history of any surgery Family History : Family History Died of heart problem known diabetic PERSONNAL HISTORY : PERSONNAL HISTORY Married Non smoker Bowel and dietary habits regular. Summary : Summary 55 years old Saudi female non diabetic with history of retrosternal chest pain since 05 days which was increase on admission day continuous for the last half hour with sweating and shortness of breath. Differential diagnosis : Differential diagnosis ACUTE MYOCARDIAL INFARCTION UNSTABLE ANGINA PEPTIC ULCER DISEASE PULMONARY EMBOLISM Examination : Examination Middle aged female with average height and built, orthopnic, anxious and worried. Pulse: 110b/min, regular, low volume BP: 80/ 60 mmhg Temperature: 36.8 Examination : Examination JVP raised 12cm No anemia or jaundice No xanthelsema No Peripheral cyanosis No clubbing or splinter hemorrhage No carotid bruit No neck swelling Examination : Examination No palpable lymph nodes No radio femoral delay No lower limb or sacral edema No rashes Cardiovascular examination : Cardiovascular examination Apex beat not visible No pulsation in pericardial region Apex beat palpable in 5th intercostal space non sustained. No thrill or heave S1 and S2 with normal intensity. Respiratory system : Respiratory system Chest bilaterally symmetrical moving with respiration. Vesicular breathing No crepits or ronchi Abdominal exam : Abdominal exam No hepatosplenomegaly CNS Exam: Normal sensory and motor exam Summary : Summary 55 years old Saudi female non diabetic with history of retrosternal chest pain since 05 days but severe on day of admission with sweating and SOB, orthopnic, tachycardiac, hypotensive and have raised JVP. Differential diagnosis : Differential diagnosis Acute myocardial infarction Pulmonary embolism Investigation : Investigation Chest x ray: Normal cardiac size No pulmonary congestionCardiac enzymes: CK: 276– 2685—1941 LDH: 413– 1653– 84 AST: 40-- 409 Troponin T: 10.66 : Chest x ray: Normal cardiac size No pulmonary congestionCardiac enzymes: CK: 276– 2685—1941 LDH: 413– 1653– 84 AST: 40-- 409 Troponin T: 10.66 Final diagnosis : Final diagnosis Acute inferior wall ST Elevation myocardial infarction with Right ventricular extension TREATMENT : TREATMENT I/V FLUID STREPTOKINASE ASA STATIN Right ventricular infarction : Right ventricular infarction Inferior myocardial infarction associated with Right ventricular infarction defines a high risk subset with a mortality rate of 25-30% as opposed to an overall mortality of about 6% in inferior MI. The infarction usually involve the posterior septum and posterior wall rather than RV free wall. Slide 29: Right ventricular infarction occurs when there is an occlusion of the right coronary artery proximal to the acute marginal branches, but it may also occur with an occlusion of the left circumflex artery in patients who have left-dominant coronary circulation Slide 30: Right ventricular infarction complicates 30-50% of inferior wall MIs, and 10% of anterior wall infarcts However clinical or haemodynamic evidence of RV infarction is present in less then 10% of patients with inferior infarction. Slide 31: Right ventricular function improves in the majority of patients with right ventricular infarction. This observation suggests that the right ventricular dysfunction is usually due to ischemic myocardium that remains viable. On examination: : On examination: Prominent jugular venous distension Kussmauls sign and pulses paradoxus may be present In fact Kussmauls sign in the setting of inferior MI is highly predictive of RV infarction. Clear lungs Slide 33: The clinical triad of hypotension, clear lung fields, and elevated jugular venous pressure in a patient with an inferior infarction is virtually pathgnomonic for right ventricular infarction. However, this triad has a sensitivity of less than 25 percent. Electrocardiography: : Electrocardiography: ST-segment elevation in lead V4R remains the most predictive electrocardiographic finding for right ventricular infarction. A 1-mm ST-segment elevation in this lead was 70 percent sensitive and 100 percent specific for right ventricular infarction. Echocardiography : Echocardiography Abnormal findings include right ventricular dilatation, right ventricular wall asynergy, and abnormal interventricular septal motion The short-axis view has been shown to have the highest sensitivity (82 percent), with a specificity ranging from 62 to 93 percent for hemodynamically important right ventricular infarction Complications : Complications Shock. 2nd or 3rd degree heart block Atrial fibrillation [1/3 of RVIs] Ventricular arrhythmias. Complications : Complications Ventricular septal rupture Right ventricular thrombus formation and subsequent pulmonary embolism, Tricuspid regurgitation Pericarditis [due to the frequent transmural injury of the relatively thin-walled right ventricle]. Treatment : Treatment The major objective in treating RV infarction are to maintain RV preload, provide ionotropic support, reduce after load of RV and achieve early reperfusion. Treatment : Treatment 1. Maintain Right Ventricular Preload Volume load – The initial step in managing hypotension should consist of volume loading with 1-2 L of isotonic sodium chloride solution over a 1- to 2-hour period. Although volume loading increases RAP and PCWP, it does not increase cardiac output Avoid nitrates, diuretics, morphine boluses [these ¯ preload] Maintain atrioventricular synchrony: AV sequential pacing for complete heart block Prompt cardioversion for atrial fibrillation Treatment : Treatment 2.Ionotropic support If volume loading does not correct hypotension and restore cardiac output, then ionotropic support with dobutamine may be attempted Dobutamine is the agent of choice, then adrenaline or noradrenaline, dopamine. Dobutamine increases cardiac output, stroke volume index and RVEP, consequently unloading the right ventricle. Treatment : Treatment 3. Reducing Right ventricular afterload Intra aortic balloon counter pulsation Vasodilators [sodium nitroprusside] Caution: these may also decrease LV preload and thus cardiac output. Key Points : Key Points 1. The Right Ventricle is anatomically and physiologically designed to serve the low pressure pulmonary circulation 2. Right ventricular infarction occurs when there is an occlusion of the right coronary artery proximal to the acute marginal branches. 3. Right ventricular infarction complicates 30-50% of inferior wall MIs, and 10% of anterior wall infarcts. Key Points : Key Points 4. Haemodynamic insufficiency in the presence of inferior wall myocardial infarction suggests additional right ventricular infarction 5. It is vital to maintain LV preload and RV afterload to minimise LV dysfunction. 6. Right bundle-branch block and complete heart block are the most frequent conduction abnormalities associated with right ventricular infarction. 7. Long-term outcome depends on the degree of concomitant left ventricular dysfunction. Slide 44: THANK YOU You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
myocardial infarction drjawed1974 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 578 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: January 27, 2011 This Presentation is Public Favorites: 0 Presentation Description ACUTE INFERIOR MYOCARDIAL INFARCTION WITH RIGHT VENTRICULAR EXTENSION, Comments Posting comment... By: ahmedhafez2030 (13 month(s) ago) بارك الله فيكم ونفع بكم رائع جدا Saving..... Post Reply Close Saving..... Edit Comment Close By: ahmedhafez2030 (13 month(s) ago) بارك الله فيكم ونفع بكم رائع جدا Saving..... Post Reply Close Saving..... Edit Comment Close By: ahmedhafez2030 (13 month(s) ago) بارك الله فيكم ونفع بكم رائع جدا Saving..... Post Reply Close Saving..... Edit Comment Close By: ahmedhafez2030 (13 month(s) ago) بارك الله فيكم ونفع بكم رائع جدا Saving..... Post Reply Close Saving..... Edit Comment Close By: ahmedhafez2030 (13 month(s) ago) بارك الله فيكم ونفع بكم رائع جدا Saving..... Post Reply Close Saving..... Edit Comment Close loading.... See all Premium member Presentation Transcript CASE PRESENTATION : CASE PRESENTATION DR. JAWED Age: 55 yearsSex: FemaleOccupation : House wifeAddress: al hassa : Age: 55 yearsSex: FemaleOccupation : House wifeAddress: al hassa Presenting complain : Presenting complain Chest Pain since 05 days History of present illness : History of present illness 50 years old Saudi female presented in Emergency room with history of retro sternal chest pain since 05 days, initially mild and intermittent occur on rest as well as on exertion remain for about 5 minutes then relieved spontaneously without any medication. History of present illness : History of present illness She didn't consult to any doctor during these 5 days, until on day of admission when pain was severe diffuse all over the chest, continuous for 30 minutes, like burning sensation, radiating to left shoulder, associated with sweating and shortness of breath. Pain not relieved by rest, Pain not increase by inspiration or changing in position, no palpitation, no history of fever, no history of fall down or any trauma. She went to near by clinic where she was given symptomatic treatment and referred to KFHH : Pain not relieved by rest, Pain not increase by inspiration or changing in position, no palpitation, no history of fever, no history of fall down or any trauma. She went to near by clinic where she was given symptomatic treatment and referred to KFHH Review of systems : Review of systems General: No loss of weight No malaise or weakness No sleep disturbance GIT: No abdominal pain or vomiting No Diarrhea or constipation No hemetamesis or malena Slide 8: Respiratory system: No difficulty in breathing No coughGenito urinary: No burning micturation No haematuriaCNS: No epilepsy No paralysis PAST HISTORY : PAST HISTORY No history of diabetes No history of hypertension No history of any surgery Family History : Family History Died of heart problem known diabetic PERSONNAL HISTORY : PERSONNAL HISTORY Married Non smoker Bowel and dietary habits regular. Summary : Summary 55 years old Saudi female non diabetic with history of retrosternal chest pain since 05 days which was increase on admission day continuous for the last half hour with sweating and shortness of breath. Differential diagnosis : Differential diagnosis ACUTE MYOCARDIAL INFARCTION UNSTABLE ANGINA PEPTIC ULCER DISEASE PULMONARY EMBOLISM Examination : Examination Middle aged female with average height and built, orthopnic, anxious and worried. Pulse: 110b/min, regular, low volume BP: 80/ 60 mmhg Temperature: 36.8 Examination : Examination JVP raised 12cm No anemia or jaundice No xanthelsema No Peripheral cyanosis No clubbing or splinter hemorrhage No carotid bruit No neck swelling Examination : Examination No palpable lymph nodes No radio femoral delay No lower limb or sacral edema No rashes Cardiovascular examination : Cardiovascular examination Apex beat not visible No pulsation in pericardial region Apex beat palpable in 5th intercostal space non sustained. No thrill or heave S1 and S2 with normal intensity. Respiratory system : Respiratory system Chest bilaterally symmetrical moving with respiration. Vesicular breathing No crepits or ronchi Abdominal exam : Abdominal exam No hepatosplenomegaly CNS Exam: Normal sensory and motor exam Summary : Summary 55 years old Saudi female non diabetic with history of retrosternal chest pain since 05 days but severe on day of admission with sweating and SOB, orthopnic, tachycardiac, hypotensive and have raised JVP. Differential diagnosis : Differential diagnosis Acute myocardial infarction Pulmonary embolism Investigation : Investigation Chest x ray: Normal cardiac size No pulmonary congestionCardiac enzymes: CK: 276– 2685—1941 LDH: 413– 1653– 84 AST: 40-- 409 Troponin T: 10.66 : Chest x ray: Normal cardiac size No pulmonary congestionCardiac enzymes: CK: 276– 2685—1941 LDH: 413– 1653– 84 AST: 40-- 409 Troponin T: 10.66 Final diagnosis : Final diagnosis Acute inferior wall ST Elevation myocardial infarction with Right ventricular extension TREATMENT : TREATMENT I/V FLUID STREPTOKINASE ASA STATIN Right ventricular infarction : Right ventricular infarction Inferior myocardial infarction associated with Right ventricular infarction defines a high risk subset with a mortality rate of 25-30% as opposed to an overall mortality of about 6% in inferior MI. The infarction usually involve the posterior septum and posterior wall rather than RV free wall. Slide 29: Right ventricular infarction occurs when there is an occlusion of the right coronary artery proximal to the acute marginal branches, but it may also occur with an occlusion of the left circumflex artery in patients who have left-dominant coronary circulation Slide 30: Right ventricular infarction complicates 30-50% of inferior wall MIs, and 10% of anterior wall infarcts However clinical or haemodynamic evidence of RV infarction is present in less then 10% of patients with inferior infarction. Slide 31: Right ventricular function improves in the majority of patients with right ventricular infarction. This observation suggests that the right ventricular dysfunction is usually due to ischemic myocardium that remains viable. On examination: : On examination: Prominent jugular venous distension Kussmauls sign and pulses paradoxus may be present In fact Kussmauls sign in the setting of inferior MI is highly predictive of RV infarction. Clear lungs Slide 33: The clinical triad of hypotension, clear lung fields, and elevated jugular venous pressure in a patient with an inferior infarction is virtually pathgnomonic for right ventricular infarction. However, this triad has a sensitivity of less than 25 percent. Electrocardiography: : Electrocardiography: ST-segment elevation in lead V4R remains the most predictive electrocardiographic finding for right ventricular infarction. A 1-mm ST-segment elevation in this lead was 70 percent sensitive and 100 percent specific for right ventricular infarction. Echocardiography : Echocardiography Abnormal findings include right ventricular dilatation, right ventricular wall asynergy, and abnormal interventricular septal motion The short-axis view has been shown to have the highest sensitivity (82 percent), with a specificity ranging from 62 to 93 percent for hemodynamically important right ventricular infarction Complications : Complications Shock. 2nd or 3rd degree heart block Atrial fibrillation [1/3 of RVIs] Ventricular arrhythmias. Complications : Complications Ventricular septal rupture Right ventricular thrombus formation and subsequent pulmonary embolism, Tricuspid regurgitation Pericarditis [due to the frequent transmural injury of the relatively thin-walled right ventricle]. Treatment : Treatment The major objective in treating RV infarction are to maintain RV preload, provide ionotropic support, reduce after load of RV and achieve early reperfusion. Treatment : Treatment 1. Maintain Right Ventricular Preload Volume load – The initial step in managing hypotension should consist of volume loading with 1-2 L of isotonic sodium chloride solution over a 1- to 2-hour period. Although volume loading increases RAP and PCWP, it does not increase cardiac output Avoid nitrates, diuretics, morphine boluses [these ¯ preload] Maintain atrioventricular synchrony: AV sequential pacing for complete heart block Prompt cardioversion for atrial fibrillation Treatment : Treatment 2.Ionotropic support If volume loading does not correct hypotension and restore cardiac output, then ionotropic support with dobutamine may be attempted Dobutamine is the agent of choice, then adrenaline or noradrenaline, dopamine. Dobutamine increases cardiac output, stroke volume index and RVEP, consequently unloading the right ventricle. Treatment : Treatment 3. Reducing Right ventricular afterload Intra aortic balloon counter pulsation Vasodilators [sodium nitroprusside] Caution: these may also decrease LV preload and thus cardiac output. Key Points : Key Points 1. The Right Ventricle is anatomically and physiologically designed to serve the low pressure pulmonary circulation 2. Right ventricular infarction occurs when there is an occlusion of the right coronary artery proximal to the acute marginal branches. 3. Right ventricular infarction complicates 30-50% of inferior wall MIs, and 10% of anterior wall infarcts. Key Points : Key Points 4. Haemodynamic insufficiency in the presence of inferior wall myocardial infarction suggests additional right ventricular infarction 5. It is vital to maintain LV preload and RV afterload to minimise LV dysfunction. 6. Right bundle-branch block and complete heart block are the most frequent conduction abnormalities associated with right ventricular infarction. 7. Long-term outcome depends on the degree of concomitant left ventricular dysfunction. Slide 44: THANK YOU