candidate of medical sciences, associate

professor of internal medicine 2 department

Yakubovsyka I.A
4.8. complications of acute myocardial infarction I23

Acute heart failure (I-IV classes for Killip I50.1
Cardiac rhythm and conduction I44, I49
Breaking hearts external and internal (atrial septal defect -
ventricular septal defect, tendon rupture chord, papillary
muscle rupture
hromboembolism different localization I23.8
lood clots in the cavities of the heart I23.6
cute aneurysm (corresponding code from I23.8
Dressler's syndrome (which is code I24.1
ostinfarction angina (after 3 to 28 days) I20.0
COMPLICATIONS
myocardial infarction
There are in 10-15% of patients.
Really affect mortality
mechanically
reactively
ELECTRICAL
hemodynamic
ELECTRICAL
COMPLICATIONS ACS
Tachy - bradyarrhythmias, conduction disorders
EARLY
during the first 48 h
of the first symptoms
LATE
after 48 h from the start
Clinic of acute myocardial infarction

Front infarcts (25-30%) increase in activity
Sympathetic nervous system - Tachyarrhythmias
Lower infarcts (10-40%) increase in activity
parasympathetic nervous system- Bradyarrhythmias
I group: ST, SB, AV I complications of treatment not require
II group: AVII, ventricular extrasystoles( II-IV kl) FA, SVT, LBBB
III group: ventricular tachycardia, ventricular fibrillation, asystole,
EMD, complete AV block complications requiring emergency
tretment
Where is localization of
myocardial infarction?
ASSERT
First vice rector
professor ______H. M. Erstenyuk
Ministry of health Ukraine
Ivano-Frankivsk national medical university
Foreign Citizens Training Faculty
PRACTICALLY ORIENTED STATE EXAMINATION
speciality 7.110101 internal medicine, 7.110104 pediatry
Discipline: internal medicine

Head of department of internal medicine 2
PhD, professor N.M.Seredyuk


Head of department of internal medicine 4 and nursing
PhD, professor I.P. Vakaliuk


Ventricular extrasystoles
begimeniya
group extrasystoles
bisystoliya
atrials fibrillation
f
f
F F F F F F
F
F F F
f
f
f
f
f f
ventricular paroxysmal tachycardia
ventricular paroxysmal tachycardia
ventricular fibrillation
Sudden cardiac death,
due to ventricular fibrillation

inversion
T wave - ischemia
Group ventricular
extrasystoles
Ventricular paroxysmal
Tachycardia
with the transition to ventricular fibrillation
ventricular fibrillation
no effect
repeat three defibrillation 200-300 j
no effect

repeat three defibrillation 360 J
Enter consistently intravenous epinephrine 1 mg and 1.5 mg / kg lidocaine
repeat three defibrillation
Enter consistently intravenous epinephrine 1 mg and 1.5 mg / kg lidocaine
If lidocaine is ineffective, assign CORDARONE (150-450 mg)
repeat three defibrillation
Prekardial hit/ unsynchronized electrical cardioversion
the first charge of 200 joules
Algorithm for the treatment of ventricular tachycardia
(American College of Cardiology, 1999)
no effect
The treatment of
arrhythmias will be
considered in lectures
devoted to arrhythmia
has three causes
ventricular fibrillation
asystolea
electro-mechanical dissociation

Treatment - resuscitation
Algorithm and method of cardio-pulmonary
and cerebral intensive care (resuscitation)


A Air way providing Cleaning oral cavity and respiratory tracts.
B Breath for victum artificial ventilation of lungs by air, which
doctor inhales by the method mouth-to-mouth, mouth-to-nose
or by a ventilation machine.
C Circulation of the blood artificial support of blood circulation
(indirect massage of heart it is now recommended to do the first).
D Drugs injecting of medicines.
E Electrocardiography ECG registering.
F Fibrillation electric defibrillation (cardioversion).
G- Gauge an estimation of primary results.
H Hypothermy of body
I Intensive care providing of intensive therapy
A Air way providing of the free communicating of
respiratory tracts
Peter Safar: Triple reception and endotracheal intubation.
Alternative endotracheal intubation: laryngeal mask or
bidirectional povitryaprovid Combitube
1. Cleaning oral cavity
with finger.
2. Ensuring a patent
airway by rejection
head backwards.
3. Ensuring a patent airway
by the withdrawal of the
mandible.
A triple reception of Peter Safar
Breathing with methods mouth-to-moth (a)
and mouth-to-nose (b)
B.- Breath for victum Breathing capacity must be 500-600 ml
(6-7 ml / kg). In exhaled air of Reanimator is only 16-17%
O2 and 3,5-4,0% CO2.
. Artificial support of blood circulation.
A precardiac beat is conducted only, when doctor sees on a monitor
beginning of ventricles fibrillation or tachycardia without pulse, and there is
no defibrillator in this moment. Its done only during first 10 seconds after
stop of blood circulation. In other cases not used, because a rhythm can
be transformed in an asystolea.
Method of making of precardiac beat.
From distance 20 sm doctor carries
out beat by a fist for sternum (limit of
middle and lower third part of
sternum) with a clamp in the end on a
few seconds.


. Artificial support of blood circulation
conducted by the compression on the thorax. The correct compression of
thorax supports SBP at the level of 60-80 mm Hg. Thus a level of cerebral
blood flow is 30-60 % from a norm, coronal 5-20% from a norm. The
number of inhalations and number of compressions is 2:30 (regardless of
amount of doctors picture a, b) . Quantity compressions of thorax
100/min, frequency of breathings 10/min.

)
)
)

2
1

2
)
Electrical defibrillation of the heart:
a) blending electrodes during
electrical defibrillation of the heart:
1 - cathode electrode is the right of
the sternum below the clavicle;
2 - anode electrode is left of the
apex of the heart.
b) portable defibrillator biphase
with voice prompt.
1
2
)

. Artificial support
of blood circulation
Defibrillation
automatic external defibrillator should be





automatic external defibrillator should be
automatic external defibrillator should be



CORDARONE - the drug of choice for VF / TS Are refractory to 3
initial digits defibrillator.
CORDARONE 300 mg diluted in 20 ml of 5% glucose district and
injected bolus, then i / - 1 mg / min 6 h, then - 0.5 mg / min to
a maximum dose of 2000 mg.
Lidocaine and / or novokainamid is an alternative to CORDARONE
with insufficient effect or intolerance last [not tolerate
lidocaine and CORDARONE to enter together!].
Lidocaine impose 80 mg / per jet, then / in 2 mg / min. The total
dose is 3 mg / kg over 1 hour.
Novokainamid IV (no bolus) - 30 mg / min to a total dose of 17
mg / kg body weight of the patient.
Adrenalin - facilitates blood flow to the coronary and cerebral
vessels during indirect heart massage, promotes transition that
is easier to deal with cardioversion.
Dosage: 1 mg every 3-5 minutes.

(continued)

Atropine - with bradyarrhythmias / asystoliyib
single dose of 3 mg. [Former clinical protocols
required to enter atropine 1 mg every 3 minutes to the
total dose of 0.4 mg / kg body weight].
Magnesium sulfate (8 mmol - 4 ml of 50% solution)
is recommended for refractory VF, with spindly
polymorphic VT overdose thiazide and loop
diuretics.
Aminophylline - 2.4% 250-500 mg (5 mg / kg) in /
with asystole and bradyarrhythmias.
MECHANICAL COMPLICATIONS
ACS
Rupture and / or papillary muscle dysfunction, acute mitral
insufficiency.
Gaps left ventricular free wall and / or septum
(pansystolichnyy noise).
Low cardiac output syndrome (DL).
Aneurysm of the left ventricle (with m Kazm-Beck, LA II).
Expansion of myocardial infarction and post-myocardial
infarction remodeling.
Hemodynamic IMPORTANT MYOCARDIAL INFARCTION RV
- Shock, hypotension, tricuspid insufficiency,
- Increased central venous pressure,
- Right ventricular gallop, no congestion in the lungs,
- Symptom Kussmaul, swelling on inspiration jugular veins
- Signs of inferior myocardial infarction
- ST segment elevation contours over in V3R and V4R, V7 - V9 in the
presence of left ventricular myocardium lower wall.
Echocardiography: RV dilatation, segmental contractility disorders.
Blood: troponin T, I-positive reaction.
.
MECHANICAL
COMPLICATIONS ACS

SYNDROME expansion and postinfarction
remodeling
The left ventricle
necrosis
and then
scar
expansion
affected
wall
hypertrophy
intact areas
Thinning
wall and
dilatation
cavity
Spread MI (expansion-myocardial remodeling)
A consequence of significant myocardial injury, wall
thinning and ventricular remodeling infarction, left
ventricular aneurysm formed.
Manifestations : pain is not removed, rack segment
elevation ST (frozen curve), the appearance of
arrhythmias. Contains high sTnI. Echocardiography -
hipokinekziya LV thrombus in the left ventricle is.

Relapse MI (extension myocardial infarction):
the first day positive trend restored segment ST, pain
disappears, no symptoms of heart failure, arrhythmias,
level with Ts and normalized.
After 4 - 5 days reappears angina, re-segment elevation
ST. signs of heart failure, tolerance to nitrates.
Reason - repeated reoklyuziya.
1. Acute left heart failure.
1.1. Cardiac asthma - interstitial pulmonary edema.
1.2. Pulmonary edema - alveolar pulmonary edema.
2. Acute right heart failure
(Acute cor pulmonale).
3. Cardiogenic shock syndrome (small cardiac output).
4. Acute total heart failure (Cardiac tamponade).

options:
1. instantaneous
2. Acute (1 h)
3. A prolonged (2 days)
4. Recurrent


Clinical forms of pulmonary edema:
1. Hyperdynamic
2. Hypodynamic -
CLASSIFICATION OF ACUTE
HEART FAILURE T.KILLIP,
J.KIMBALL (1997)
CLASSIFICATION OF CLINICAL
SEVERITY OF ACUTE HEART
FAILURE BY FORRESTER
I - shortness of breath, wheezing
dry, tachycardia or elevated
blood pressure or normal
IIa tachycardia, shortness of
breath, wheezing moist
auscultated <50% of the
pulmonary, blood pressure
normal or elevated
IIb - tachycardia shortness of
breath, wheezing moist
auscultated <50% of the
pulmonary, blood pressure
<90/60 mm protodiastolic
gallop (mortality 10-15%)
III - tachycardia shortness of
breath, wheezing moist
auscultated > 50% of the
pulmonary, blood pressure
<60/20, protodiastolich gallop
IV - cardiogenic shock
Class I, Group A, "warm
and dry

Class II, Group B - "warm
and wet



Class III group L - "is cold
and dry

Class IV, Group C - "is
cold and wet"

Reducing the hydrostatic pressure in the pulmonary vessels
and reduction of venous flow to the heart
(iv):
Morphine 1 ml of 1% slowly, better diluted in 20 ml 0.9% NaCl
district
and administered by 2-4 mL i.v. every 2 -3 hours
Atropine 1 ml of 0.1% slowly
Inhalation of oxygen

Neyroleptanalheziya (iv):
Droperidol 0.25% 10 mL (25 mg) + fentanyl 1 ml 0.005% (0.05 mg)
Haloperidol 0.5% 1 ml (iv)

Nitroglycerin (iv): 6 ml (60 mg) 1% in 250 ml, 2 17 cr. / Min. or
IZOKET (iv): 100 ml (100 mg) in 400 ml 0,9% NaCl, 3 17 cr. / Min.

ACE inhibitors: enalapril - 1.25 mg / in, the SBP over 100 mm. Hg
II. Reducing the volume of circulating blood and dehydration
lung
With high blood pressure:
Loop diuretics (iv):
Furosemide (Lasix), inkjet, 20-60-120mg
Ethacrynic ACID (UREHIT) 50-100 mg iv, jet
With low blood pressure: Osmodiuretics (iv):
Mannitol, urea 1 g / kg, iv 10 40 kr / min
III. Reducing the permeability of the alveolar-capillary membrane
a. Glucocorticosteroids (iv):
Prednisolone: 60-120 mg every 2 hours
Hydrocortisone: 250-500 mg every 2 hours
Antihistamines (iv):
Diphenhydramine 1-2 ml of 1%
Suprastin 1-2 ml of 2%
Improved contractile ability of the heart:
Dobutamine - 5 - 10 - 40 mg / kg.



Antianginal therapy and correction of arrhythmias and
conductivity
Fighting hypoxia, disorders of acid-base balance
Inhalation of moist oxygen - through a mask or catheter.
ANTYFOMSYLAN - inhalation 2-3 ml of 10% ethanolic district 10-15 min
Ethyl alcohol 5 ml of absolute alcohol + 15 ml of 5% glucose district, iv 20-30,0
Artificial lung ventilation using positive pressure end expiratory
Sodium hydroxybutyrate 20 ml of 20% (iv), 75-100 mg / kg
Fighting bronchospasm and improving alveolar ventilation:
Aminophylline (iv) 10 - 20 ml of 2.4% spray
Alupent (iv) 1 ml of 0.05% (0.5 mg), or jet 5 ml
+ 50 ml of 5% glucose
I degree - relatively light, duration of 3 - 5 hours.
AT 90/50 - 60/40 mm Hg. century.
Fast and stable response to pressors' amines.
II degree - moderate, duration 5 10 hours.
BP - 80/50 - 40/20 mm Hg. century.
Acute left ventricular failure. Pressors'
response to medications low and unstable.
III degree - very heavy, substantial lowering of
blood pressure, SBP <20 mm Hg. century.
Alveolar pulmonary edema. Pressers' response
to medications short-lived and unstable.
multiple organ failure due to disruption of blood circulation
MEASURES TO IMPROVE THE CENTRAL and peripheral HEMODYNAMICS
Dopamine 4% 5 ml (200 mg): 250 ml of 0.9% district NaCl,
Epinephrine 0.1% 1 ml: 4 ml + 250 ml 0,9% NaCl, 2
Dobutamine (DOBUTREKS) 2.5 mg / kg every 15 min. increase at 2.5 mg / kg
15 mg / kg
Isoproterenol (isoproterenol) 0.05% 1 ml (0.5 mg) + 500 ml of 5% glucose, 2
40 cr. / Min.
Norepinephrine 0.2% 1 ml of 2 - 4 ml (4 - 8 mg) to 1 liter of 5% glucose
Low molecular dextran (iv):
Dextran, REOHLYUMAN, reomakrodeks, REOTRAN
Antiplatelet: antiplatelet agents:
Glucocorticosteroids (iv):
Prednisolone 60 mg or 250 mg of hydrocortisone that 2 h.
Sodium bicarbonate (iv): ml 5% NaHCO3 = BE x body weight x 0.5
Mmol / l 8,4% NaHCO3 = BE x body weight x 0.3
Mmol / l 4,2% NaHCO3 = BE x body weight x 0.2 x 2
TRYSAMIN Ml 3.6% RE = x body weight
Combination NaHCO3: trysbufer = 1:1
LEVRSYMENDAN




In case of increased CVP:
Droperidol (iv): 2 - 3 ml of 0.25% district in 250 ml of 5%
glucose district
Nitroglycerin (iv): 6 ml of 1% (60 mg) in 250 ml 0,9% NaCl,
2 17 cr. / Min. within a day
IZOKET (iv): 100 ml (100 mg) in 400 ml 0,9% NaCl,
3 17 cr. / Min. within a day
Kontrapulsation: a. femoralis in the abdominal aorta injected
spray, electronic device inflates it in the diastole, during
systole it spadayetsya. In this way, DBP and increased
perfusion of the heart.

COMPLICATIONS: NK ischemia, aortic dissection, hemolysis,
infection.

Classes:
- Large vessels (signs of shock and / or reduction in
systolic blood pressure (SBP) and 90 mmHg or
decrease SBP by 40 mm Hg. Century. Within 15
minutes. Sudden death
medium-sized vessels (there are signs of right ventricular
hypokinesia);
- Small branches (right ventricular function unchanged).
Thrombus a broad stalk in
the area in the top left
ventricular cavity
A. lung: chest pain, worse when breathing FB 30-40 per minute
without orthopnea, pleural friction rub, moist rales, hemoptysis,
accent II tone over a.pulmonalis, noise-Graham
Still, reinforced and tons of projection t trikuspidalnoho valve.
B. Heart: amplified heart beat, palpitations, tachycardia, collapse
without bolevogo syndrome.
C electrocardiographic syndrome Mc Jin-White (SI, QIII, T III,
descending elevation STIII, aVF, V1-3, ST depression in I, aVL,
V5-6leads, P-pulmonale; blockade of right bundle branch block).
G. Radiological findings: symptom Westermarck (local absence of
pulmonary figure), wedge-shaped shade.
D. Ultrasound (thrombus).
J. Laboratory: D-dimers fibrinogen> 500od
Q. CT, spiral CT.
I. radioisotope scintigraphy (scan of the lungs).
K. angiopulmonografiya.
syndrome Mc Jin-White (SI, QIII, T III,
descending elevation STIII, aVF, V1-3,
ST depression in I, aVL, V5-6leads,
P-pulmonale; blockade of right bundle branch block
Morphine 1 ml of 1% slowly, better diluted in 20 ml 0.9%
NaCl district + Inhalation of moist oxygen
Thrombolytic therapy (therapeutic window to 6 hours)
Aktylize rt PA: 15 mg bolus, 50 mg, 30 min, 35 mg and 60
min, in / tively.
Heparin 5000 IU bolus 1 thousand IU / h, c / tively h /
Lineomat or low molecular weight heparin: enoxaparin - 1
mg / kg x 2p / d, sc, 6 2 days, or FONDAPARYN UCU
(Arixtra) 2.5 mg , sc, 1p /e
Warfarin 10 mg / d, po 5 days and then 3-5 mg / d to a year,
INR 2-3.
Aspirin 125 mg / d, po 1-9 months/ Clopidogrel - 75 mg / d 1-
9 months
Endovascular embolectomy
Venous filters
Complication of myocardial
Infarction
Reactive:

- Pericarditis epistenocardica
- Postinfarction syndrome Dreslera
- Trombendokardyt
- Early postinfarction angina
- Erosion and ulceration of the gastrointestinal tract,
gastric bleeding
- Paresis gastrointestinal
- Atony bladder
- Somatogenic psychosis
complications of myocar
infarction
syndrome Dreslera
2 weeks after of acute MI as
autoimmune reaction to injury
polyserositis with lesions
perikardu, pleura, joints prolonged
fever, leukocytosis, high erythrocyte
sedimentation rate
Effective corticosteroids, NSAIDs

red - the right hand
yellow - the left hand
green - the left leg
black - on the right foot
I - between the right-
hand left-hand
I - between right hand
and left leg
III - between left hand
and left leg
Electrodes imposes
Standard (, , ) leads

avR ( II) from the right hand
aVL ( I) - from the left hand
aVF ( III) from the left leg
augmented (aVR, aVL, aVF) leads
- augmented
V - voltage
R - ringht
L - left
F - foot
Geometric scheme of leads according to
V.Einthoven
Standard (, , ) and augmented (aVR,
aVL, aVF) leads from extremities.
V6R
V5R
V4R V3R
V1 V2
V3
V4
V5
V6
The first position (V1) is
contained in V intercostal
space on the right edge of
sternum, it answers the
projection of front wall of right
ventricle.
Second position (V2) in
V intercostal space to the left
sternum, it answers the
projection of front wall of right
ventricle and partly
interventricular septum.
Third position (V3) in V
intercostal space for linea
parasternalis sinistra, answers
the projection of area of
membrane of heart (R= S).
Fourth position (V4) in V intercostal space on left middling clavicular lines,
answers the projection of apex of heart.
Fifth position (V5) on a front armpit line in V intercostal space.
Sixth position (V6) is contained on a middle armpit line in V intercostal space.
Two last positions answer projection front-lateral walls of the left ventricle.
electrode from the left hand
electrode from the left foot
electrode
from the
right hand


aVR
aVL
aVF
V1
V4
V2
V5
V3
V6
Practical skills: analysis and estimation of
electrocardiograms
Electrocardiogram 4
Give interpretation of this research
Ministry of health Ukraine
Ivano-Frankivsk state medical university
Medical faculty
PRACTICALLY ORIENTED STATE EXAMINATION
Discipline: internal, professional and infectious illnesses
Head of department of internal medicine 2 d.med.k., professor
N. M. Seredyuk


Thank you for
your attention