الفهرس 
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Abstract
Myocardial Ischemia means narrowing of Coronaries whatever it was transient or permanent, partial or complete, painful or silent, recurrent or firstly experienced, recordable or not. This, Although chambers are full of blood, makes heart muscle blood supply decreases and if it continued it may result in myocardium permanent damage ( Myocardial infarction )
PRESENTATION:
Signs and Symptoms
Symptoms : dyspnea with typical or atypical crushing chest pain, sever or vary in intensity , persisting for 15 minutes or more
Often accompanied by sweating; may also have nausea, belching or vomiting. Resistant to analgesics or silent , relieved by rest, sublingual nitrates, morphia or not relieved. Patient may give history of similar attacks before and the way it relieved with.
INVESTIGATIONS :
ECG findings: No finding ,ST segment elevation, Q-waves, and a conduction defect, if such findings are new compared with a previous ECG. New T-wave inversion also increases the likelihood of MI .None of these findings is sensitive enough that its absence can exclude MI.
Elevated Cardiac Enzymes and Protein
- Creatine kinase (CK)
- The MB isoenzyme of creatine kinase (CK-MB),
- Troponin T and troponin I
PREVENTION::
1. Primary Prevention (Risk factor screening)
Goal: Adults should know the levels and significance of risk factors as routinely assessed by their primary care provider .
Begin risk factor assessment in adults at the age of 20.
Update family history of coronary heart disease (CHD) regularly.
Assess smoking status, diet, alcohol intake and physical activity at every routine evaluation.
Record blood pressure (BP), body mass index (BMI), at each visit (at least every two years).
Measure fasting serum lipoprotein profile (or total and HDL cholesterol if fasting is unavailable) and fasting blood glucose according to the person’s risk for hyperlipidemia and diabetes, respectively (at least every five years; if risk factors are present, every two years).57
Smoking
Increasing the awareness of the danger of smoking among youth through media and campaigns opposing smoking that spreads to include children at schools as the age of smoking has declined to be less than 10 years
Encourage every smoker to quit.
Warning against the danger of passive smoking.
Blood pressure control
Goal: Less than 120/80 mm Hg; for people who have been diagnosed with high blood pressure, the goal is less than 140/90 mm Hg; less than 130/80 mm Hg in people with renal (kidney) disease or diabetes.
Promote healthy lifestyle modification. Advocate reducing weight; reducing sodium (salt) intake to less than 2300 mg a day; eating fruits, vegetables and low-fat dairy products; moderating alcohol intake; and at least 30 minutes of physical activity on most or all days of the week.
For people with renal (kidney) disease or diabetes, start drug therapy if BP is 130 mm Hg or greater systolic or 80 mm Hg or greater diastolic.
Start drug therapy for those with BP of 140/90 mm Hg or greater if BP goal is not achieved with lifestyle modifications. Add blood pressure medications, individualized to the patient’s other requirements and characteristics ( age, race or need for drugs with specific benefits).
Dietary intake
Goal: An overall healthy eating pattern.:
Advocate eating a variety of fruits, vegetables, grains, legumes, fat-free or low-fat dairy products, fish, poultry and lean meats.
Match energy (calorie) intake with energy needs and make appropriate changes to achieve weight loss when needed.
Modify food choices to reduce saturated and trans fats to less than 10 percent of calories, cholesterol to less than 300 mg per day, and trans fats. (Trans fats result from adding hydrogen to vegetable oils.) Substitute grains and unsaturated fats from fish, vegetables, legumes and nuts.
Limit salt intake to less than 6 grams per day (2,300 mg of sodium).
Aspirin
Goal: Low-dose aspirin in people at higher risk of coronary heart disease (especially those with a 10-year CHD risk of 10 percent or greater).
Benefits of reducing cardiovascular risk outweigh these risks in most patients with higher coronary risk.
Consider 75–160 mg aspirin per day for people at higher risk (especially those with a 10-year CHD risk of 10 percent or greater).58
Blood lipid management
LDL cholesterol less than 160 mg/dL if no more than one risk factor is present.
LDL cholesterol less than 130 mg/dL (less than 100 mg/dL is an option) if two or more risk factors are present and 10-year CHD risk is less than 20 percent.
LDL cholesterol less than 100 mg/dL (less than 70 mg/dL is an option for very high-risk patients) if two or more risk factors are present or higher or if person has diabetes. Secondary goals (if LDL cholesterol is at goal range): If triglycerides are greater than 200– 499 mg/dL then use non-HDL cholesterol as a secondary goal:
Non-HDL cholesterol less than 190 mg/dL for no more than one risk factor.
Non-HDL cholesterol less than 160 mg/dL for two or more risk factors.
Non-HDL cholesterol less than 130 mg/dL for diabetes or for two or more risk factors.
If LDL cholesterol is above goal range,
o Start therapeutic lifestyle changes diet to lower it: less than 7 percent of calories from saturated fat and less than 200 mg per day of dietary cholesterol.
o If more LDL cholesterol lowering is needed, add dietary options (plant stanols/sterols not to exceed 2 g per day and/or soluble fiber 10–25 g per day); emphasize weight reduction and physical activity.
o Rule out secondary causes of high LDL cholesterol (liver function tests, thyroid function tests, and urinalysis).
After 3 months of TLC, consider LDL-lowering drug therapy if:
o Two or more risk factors are present, and LDL cholesterol is 130 mg/dL or greater.
o No more than one risk factor is present, and LDL cholesterol is 190 mg/dL or greater.
Start drugs and advance dose to bring LDL cholesterol into range, usually with a statin, but also consider bile-acid-binding resin or niacin.
If the LDL cholesterol goal is not achieved, consider combination drug therapy (statin plus resin or statin plus niacin).
After LDL cholesterol goal has been reached, consider triglyceride level:
o If triglycerides are 150–199 mg/dL, treat with therapeutic lifestyle changes (TLC).
o If triglycerides are 200–499 mg/dL, treat high non-HDL cholesterol with TLC and, if needed, consider higher doses of statin or adding niacin or fibrate.
o If triglycerides are 500 mg/dL or greater, treat with fibrate or niacin to reduce the risk of pancreatitis.
If HDL cholesterol is less than 40 mg/dL in men and less than 50 mg/dL in women, start or intensify TLC. For higher-risk patients, consider drugs that raise HDL cholesterol (niacin, fibrates, statins).59
Physical activity
Goal: At least 30 minutes of moderate-intensity physical activity on most, and preferably all, days of the week.
If a patient has suspected cardiovascular, respiratory, metabolic, orthopedic or neurological disorders, or is middle-aged or older and sedentary, he or she should consult a physician before starting a vigorous exercise program.
Moderate-intensity activities (40 to 60 percent of maximum capacity) are equivalent to a brisk walk (15–20 minutes per mile).
Vigorous-intensity activities (more than 60 percent of maximum capacity) offer added benefits.
Recommend resistance training with eight to 10 different exercises, 1–2 sets per exercise, and 10–15 repetitions at moderate intensity on two or more days per week.
Include flexibility training and an increase in daily lifestyle activities to round out the regimen.
Weight management
Goal: Achieve and maintain desirable weight (body mass index 18.5–24.9 kg/m2). When a person’s BMI is 25 kg/m2 or higher, the waist measurement goal is less than 40 inches for men, and less than 35 inches for women :
Start a weight-management program through restricting calories in diet and increasing caloric expenditure (exercise) as appropriate.
For overweight or obese persons, reduce body weight by 10 percent in the first year of therapy.
Diabetes management
Goal: HbA1c of less than 7 percent :
Start appropriate therapy to achieve near-normal fasting plasma glucose or as indicated by near-normal HbA1c. The first step is diet and exercise.
Second-step therapy is usually oral hypoglycemic drugs: sulfonylureas and/or metformin with ancillary acarbose and thiazolidinediones. Third-step therapy is insulin.
Treat other risk factors more aggressively. For example, change BP goal to less than 130/80 mm Hg for patients with high blood pressure, and LDL cholesterol goal to less than 100 mg/dL or lower.
2. Secondary Prevention Identifying and treating people with established disease and those at very high risk of developing cardiovascular disease.
Treating and rehabilitating patients who’ve had a heart attack or stroke to prevent another cardiovascular or cerebrovascular event.
What can secondary prevention achieve?
extend overall survival.
improve quality of life.60
decrease need for interventional procedures such as angioplasty and bypass grafting.
reduce the incidence of subsequent heart attack (myocardial infarction).
Heart or stroke patients can do this to help lower their risk of recurring disease:
An assessment of fasting lipid profile.
30–60 minutes physical activity, preferably daily, or at least five days / week.
Weight adjustment to the ideal, by sticking to a diet and exercise program.
Checking blood pressure regularly. adjustment by medication. weight control, physical activity, modifying sodium (salt) intake.
Considering aspirin intake daily or another medication.
Nicotine replacement methods and formal programs to help quitting smoking.
Smoking
Goal: Complete cessation.
Intervention recommendations
Ask about tobacco use status at every visit.
Advise patient and family members to quit.
Assess the tobacco user’s willingness to quit.
Assist by counseling and developing a plan for quitting.
Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and bupropion).
Urge avoidance of exposure to environmental tobacco smoke at work and home.
Blood pressure control
Intervention recommendations
For all patients, initiate or maintain lifestyle modification (weight control, increased physical activity, alcohol moderation, sodium reduction, and emphasis on increased consumption of fresh fruits, vegetables and low-fat dairy products).
For patients with blood pressure 140/90 mm Hg or greater (or 130/80 mm Hg or greater for individuals with chronic kidney disease or diabetes): As tolerated, add blood pressure medication, initially treating with beta blockers and/or ACE inhibitors, with addition of other drugs such as thiazides as needed to achieve goal blood pressure.
Lipid management
Start dietary therapy. Reduce intake of saturated fat (to less than 7 percent of calories) trans-fatty acids, and cholesterol (to less than 200 mg dietary cholesterol per day).
Adding plant stanol/sterols (2 grams/day) and viscous fiber (more than 10 grams/day) will further lower LDL-C.
Promote daily physical activity and weight management.61
Encourage increased intake of omega-3 fatty acids in the form of fish or in capsule form (1gram/day) for risk reduction. For treating elevated triglycerides, higher doses are usually necessary for risk reduction.
For lipid management:
Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. If patients are hospitalized, initiate lipid-lowering medication before discharge as follows:
If baseline LDL-C is 100 mg/dL or greater, initiate LDL-lowering therapy (typically with a statin).
If on-treatment LDL-C is 100 mg/dL or greater, intensify LDL-lowering drug therapy (may require LDL-lowering drug combination [statin + ezetimibe, bile acid sequestrant, or niacin*]).
If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat to LDL-C less than 70 mg/dL.
If triglycerides are 200 to 499 mg/dL, non-HDL-C# should be less than 130 mg/dL, and further reduction of non-HDL-C to less than 100 mg/dL is reasonable.
Therapeutic options to reduce non-HDL-C are:
More intense LDL-C–lowering therapy, or
Niacin* (after LDL-C–lowering therapy), or
Fibrate therapy# (after LDL-C–lowering therapy)
If triglycerides are 500 mg/dL or greater, therapeutic options to prevent pancreatitis are fibrate or niacin* before LDL-lowering therapy; and treat LDL-C to goal after triglyceride-lowering therapy. Achieve non-HDL-C to less than 130 mg/dL if possible. Patients with very high triglycerides should not consume alcohol.
*Dietary supplement niacin must not be used as a substitute for prescription niacin. It should not be used for cholesterol lowering because of potentially very serious side effects. #Non-HDL cholesterol is total cholesterol minus HDL cholesterol.
Physical activity
Goal: 30 minutes, 7 days per week (minimum goal, 5 days per week)
Intervention recommendations
For all patients, assess risk with a physical activity history and/or exercise test, to guide prescription.
For all patients, encourage minimum of 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, and household work).
Encourage resistance training two days per week.
Advice medically supervised programs for high-risk patients (e.g., recent acute coronary syndrome or revascularization, heart failure).62
Weight management
Goal: Body mass index (BMI) 18.5–24.9 kg/m2. Waist circumference less than 40 inches in men and less than 35 inches in women.
Intervention recommendations
Calculate BMI and/or waist circumference on each visit and consistently encourage weight maintenance/reduction through appropriate balance of physical activity, caloric intake and formal behavioral programs when indicated to maintain/achieve a BMI between 18.5 and 24.9 kg/m2.
If waist circumference (measured horizontally at the iliac crest) is 35 inches or greater in women and 40 inches or greater in men, initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated.
The initial goal of weight loss therapy should be to reduce body weight by approximately 10 percent from baseline.
Further weight loss can be attempted if indicated through further assessment.
*A BMI of 18.5 to 24.9 is considered as normal body weight. People with a BMI of 25–29.9 are considered overweight, while people with a BMI of 30 or greater are considered obese.
Diabetes management
Initiate lifestyle and pharmacotherapy to achieve near normal HbA1c.
Begin vigorous modification of risk factors (e.g., physical activity, weight management, and blood pressure control and cholesterol management as recommended above).
Coordinate diabetes care with patient’s primary care physician or endocrinologist.
Antiplatelet agents/anticoagulants
Start aspirin at 75 to 162 mg/d and continue indefinitely in all patients unless contraindicated.
patients undergoing coronary artery bypass grafting, aspirin should be started within 48 hours after surgery reduces saphenous vein graft closure. Dosing regimens ranging from 100 to 325 mg/d appear to be efficacious. Doses higher than 162 mg/d can be continued for up to one year.
Start and continue clopidogrel 75 mg/d in combination with aspirin for up to 12 months in patients after acute coronary syndrome or percutaneous coronary intervention with stent placement (one month or more for bare metal stent, three months or more for sirolimus-eluting stent, and six months or more for paclitaxel-eluting stent).
Patients who have undergone percutaneous coronary intervention with stent placement should initially receive higher-dose aspirin at 325 mg/d for one month for bare metal stent, three months for sirolimus-eluting stent, and six months for paclitaxel-eluting stent.63
Manage warfarin to international normalized ratio 2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter, and in post–myocardial infarction patients when clinically indicated (e.g., atrial fibrillation, left ventricular thrombus).
Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely.
Renin-angiotensin-aldosterone system blockers
Intervention recommendations
Angiotensin-converting enzyme (ACE) inhibitors:
Start and continue indefinitely in all patients with left ventricular ejection fraction of 40 percent or less and in those with hypertension, diabetes or chronic kidney disease, unless contraindicated.
Consider for all other patients.
Among lower-risk patients with normal left ventricular ejection fraction in whom cardiovascular risk factors are well controlled and revascularization has been performed, use of ACE inhibitors may be considered optional.
Angiotensin receptor blockers:
Use in patients who are intolerant of ACE inhibitors and have heart failure or have had a myocardial infarction with left ventricular ejection fraction of 40 percent or less.
Consider in other patients who are ACE-inhibitor intolerant.
Consider use in combination with ACE inhibitors in systolic-dysfunction heart failure.
Aldosterone blockade:
Use in post-myocardial infarction patients who do not have significant kidney dysfunction or elevated serum potassium, who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have a left ventricular ejection fraction of 40 percent or less, and have either diabetes or heart failure.
Beta blockers
Start and continue indefinitely in all patients who have had myocardial infarction, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms, unless contraindicated.
Consider chronic therapy for all other patients with coronary or other vascular disease or diabetes unless contraindicated
TREATMENT:
1. INITIAL MEASURES
o Oral nitrates and Asprin
o ECG within 5 minutes of arrival
o History and examination including BP both arms
o IV cannula
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o Oxygen if Sa02 <98% (unless history of COPD), pain relief with GTN, morphine or diamorphine, metoclopramide if pain still present
o FBC, coagulation, U+E, glucose, lipids, LFT, troponin, CK, CXR
o Consider other diagnoses e.g. PE, aortic dissection, pneumothorax
2. RISK STRATIFICATION
Calculate TIMI risk score
RISK FACTOR POINTS
Age > 65 1
≥3 CAD risk factors (↑Chol FHx, HTN, DM, Smoker, PVD) 1
Known CAD (stenosis ≥50%) 1
Aspirin use in the past 7 days 1
Severe angina (≥2 episodes in last 24 hours) 1
↑cardiac markers 1
ST deviation >0.5m 1
RISK SCORE = Total Points (0-7)
2.1 Low risk (TIMI risk score 0-2)
If the TIMI risk score is low and troponin is not elevated, aim for early discharge:
Normal ECG, age <40 and 0-1 risk factors (DM, smoking, FH premature CAD, HTN, hypercholesterolaemia, PVD) – consider alternative diagnoses. GP follow-up
Normal ECG, age >40 or ≥2 more risk factors – arrange early exercise test .Refer to cardiac assessment and Discharge with aspirin 75mg and GTN spray with advice to return if recurrent symptoms
Non-diagnostic (known pre-existing ECG abnormalities) or uninterpretable ECG (e.g. bundle branch block, LVH) – refer to cardiac assessment If angina is suspected. Discharge with aspirin 75mg od and GTN spray with advice to return if recurrent symptoms.
2.2 Moderate – High Risk (TIMI risk score 3-7)
If the patient has ECG or cardiac marker evidence of an ACS or if in the opinion of the admitting physician this is felt to be likely, treatment should be initiated immediately on admission.
Treatment should consist of:
Aspirin 300 mg then 75 mg od
Clopidogrel 300 mg then 75 mg od
Fondaparinux 2.5mg od s/c (see guideline WAHT-CAR-042)
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Beta blocker (e.g. bisoprolol 2.5 – 5mg od) titrated till HR<60 bpm
If beta blocker contra-indicated diltiazem may be used though rate control is less effective
Statin – the default for ACS cases is Atorvastatin 80 mg od. Use simvastatin 40 mg od if there are concerns regarding tolerability of high dose statin therapy
ACE inhibitor (e.g. ramipril 1.25 mg bd titrated to 5mg bd) started the day after admission if BP>100 and creatinine<200
IV nitrates if still in pain or ECG evidence of ischemia
3. ADDITIONAL THERAPIES
3.1 IIbIIIa inhibitors - In the highest risk patients, or if there is evidence of recurrent chest pain with dynamic ECG changes (especially ST depression), use glycoprotein IIbIIIa inhibitor infusion
3.2 Omega-3 fatty acids - Omacor 1gm od improves prognosis when started within 3 months of a myocardial infarction, predominantly by reducing sudden cardiac death.
3.3 Aldosterone antagonists
If heart failure with LV impairment present, consider spironolactone 25-50mg od or eplerenone 25-50mg od .Contra-indicated in hyperkalaemia or renal failure (Cr>200μmol/l). Monitor potassium
4. NURSING
- Transfer high risk ACS patients (TIMI risk 5-7) to CCU
- Manage moderate risk ACS patients initially on MAU with ECG monitoring if no cardiology bed available, but aim to transfer to Laurel 1/CCU as soon as possible
5. CARDIAC CATHETERISATION
All patients at high or moderate risk with an elevated troponin or dynamic ST depression >1mm should undergo in-patient coronary angiography and revascularisation unless there are contra-indications. Refer to cardiology/cardiology assessment sisters within 24 hours.
Even in the absence of an elevated troponin or dynamic ST changes, patients with a TIMI risk score 3-7 may still be best managed by in-patient coronary angiography. Refer to cardiology assessment within 24 hours.
Emergency cardiac catheterisation may be required if there are on-going or recurrent symptoms with dynamic ST changes or haemodynamic instability. Consult with a cardiologist
6. ECHOCARDIOGRAPHY.66
Echocardiography should be performed in all patients after MI to assess LV function. If severe LV impairment (EF<35%), consider Holter monitoring after 3 weeks to look for non-sustained VT (≥3 beats at rate >120) – consider referral for VT stimulation study and possible ICD
If EF <30% and QRS>120ms, consider referral for ICD
7. GLUCOSE CONTROL
Intensive glucose control offers benefits in patients admitted with MI.
IV insulin and glucose in all patients with STEMI and admission glucose >11.0mmol/l for 24-48 hours. Contact dialectologist when patients started on insulin
For patients known to have diabetes not treated with insulin, a period of insulin treatment is advised. Convert to s/c insulin (e.g. Novomix 30 bd regime) after 24-48 hours.
For patients known to have diabetes treated with insulin, convert to usual s/c insulin after 24-48 hours and monitor control.
For patients not known to have diabetes, stop infusion after 24-48 hours and monitor blood glucose. Contact dialectologist who will arrange a glucose tolerance test if glucose control is satisfactory.