this is a slide on myocardial infraction to figure you out what exactly it is ! though i have not mentioned the diet based causes ............etc. so enjoy

1. Myocardial infraction
(Acute coronary syndrome (ACS))
By –
Savy P. Minal & Florence Chawang

2. Introduction
Acute coronary syndrome (ACS), is a coronary artery disease in which
there is an involvement of heart due to coronary artery/arteries.
Ischemic heart disease is a condition of diverse antilogies, all having in
common a disturbance of cardiac function due to an imbalance between
O2 supply and demand.
Acute coronary syndrome (ACS), are now classified on the basis of
Echocardiography (ECG) into,
i. ST elevation Myocardial Infraction (STEMI), and
ii. Non – ST elevation Myocardial Infraction (NSTEMI)

3. STMI and NSTMI (In General)
• NSTEMI (Non–ST-segment elevation myocardial infarction) and
STEMI (ST-segment elevation myocardial infarction) are
commonly known as heart attack.
• But they are different from each other in some extent. NSTEMI
account for about 30% and STEMI about 70% of all heart
attack (myocardial infarction).
• In both cases, patients usually present with similar type of
symptoms such as chest pain, nausea, vomiting, sweating,
breathing difficulty.

4. Pathophysiology of NSTEMI vs STEMI :
(a comparison)
NSTEMI
• NSTEMI occurs by developing a
complete occlusion (blocking) of
a minor coronary artery or a
partial occlusion of a major
coronary artery previously
affected by atherosclerosis.
• This causes a partial thickness
damage of heart muscle.
STEMI
• STEMI occurs by developing a
complete occlusion of a major
coronary artery previously
affected by atherosclerosis.
• This causes a full thickness
damage of heart muscle.

5. NSTEMI STEMI

6. Clinical features of NSTEMI vs STEMI :
• Complications occur both in cases.
• But some complications like
cardiogenic shock, left ventricular
failure, severe mitral regurgitation
due to papillary muscle rupture,
cardiac troponin due to ventricular
wall rupture are more in STEMI
(due to full thickness heart muscle
damage) than NSTEMI.

7. Investigations / Diagnosis
Diagnosis can be done by number of tests:
1. Electrocardiography (ECG)
2. Blood tests
3. Chest X – Ray
4. Echocardiography
5. Radionucleotide scanning

8. Diagnosis of NSTEMI vs STEMI :
NSTEMI
• ECG - The diagnosis of a NSTEMI
is based on a typical history of
chest pain, no ST segment
elevation in ECG ,
• Blood test - Elevation of cardiac
markers in serum.
STEMI
• ECG - The diagnosis of a STEMI is
based on a typical history of
chest pain, ST segment
elevation in ECG,
• Blood test - Elevation of cardiac
markers in serum.

9. 1. Principle of Electrocardiography (ECG)

10. 1 . Electrocardiography (ECG)
• It is the most sensitive and specific method to diagnose myocardial
infraction.
• ECG may be normal initially later on, ECG should be repeated after 12
hours of chest pain to detect the changes.
• The changes are seen in the ST segment and T wave.
• A full fledged infraction may show all the three changes ST elevation, Q
wave and T wave inversion.
• These evolutionary changes may not appear in thrombolysed patients of
ST elevation MI (STMI)

11. Electrocardiogram of STEMI and MSTEMI

12. A patient of acute MI showing
character of pain by placing the
palm of his hand over anterior
chest at the site of pain and
radiation of pain to left arm and
forearm. The lower shows site of
acute MI.

13. The Serial Evolution Of
ECG Changes In Acute
Myocardial Infraction
(Diagrammatic
Representation)

14. Clinical Evaluation Of Acute Ischaemic Chest Pain
(Acute Coronary Events)

15. 2. Blood tests
A leukocytosis may be present on the first day and Erythrocyte
sedimentation rate (ESR) may be raised. Serum electrolytes, glucose, and
lipid profile should be obtained.
Plasma enzymes :
• The cardiac muscles are rich in enzymes which are released within few
hours of myocardial infraction and their peaks levels appear.
• Differential enzymes and different pattern of rise and peak levels.
• The change in enzyme level has diagnostic and prognostic values.
• Enzyme rise and fall pattern, studied in this are : CK (Creatinine kinase),
AST (Aspartate aminotransferase) and LDH (Lactic acid dehydrogenase),

16. CK (Creatinine kinase),
AST (Aspartate aminotransferase),
and
LDH (Lactic acid dehydrogenase).

17. 3. Chest X- ray
• This may detect acute
pulmonary oedema and
congestion which may not
be detected on clinical
examination.

18. 4. Echocardiography (ECHO)
• Echocardiogram , often
referred to as a cardiac
echo or simply an echo, is a
sonogram of the heart.
• Echocardiography uses
standard two-dimensional,
three-dimensional, and
Doppler ultrasound to
create images of the heart
• It is a valuable technique of
diagnosing STEMI.
An abnormal Echocardiogram. Image shows a mid-muscular
ventricular septal defect

19. Treatment of NSTEMI vs STEMI :
1. Antiplatelets (Aspirin, Clopidogrel, Ticagrelor),
2. anticoagulants (Enoxaparin, Dalteparin, Fondaparinux),
3. beta-blockers (atenolol, metoprolol, bisoprolol),
4. nitrates (isosorbide dinitrate, glyceryl trinitrate),
5. Statins (atorvastatin, rosuvastatin, simvastatin, pitavastatin),
6. ACE inhibitors (ramipril, enalapril, captopril, lisinopril) or
7. ARBs (valsartan, candesartan, losartan, olmesartan), are given
both in NSTEMI and STEMI.

20. Therapy (Treatment)
I. In case of reperfusion therapy, primary PCI (percutaneous coronary intervention) is
the treatment of choice for STEMI. Where primary PCI cannot be achieved within 120
minutes of diagnosis or PCI is not available, thrombolytic therapy such as
streptokinase, tenecteplase, alteplase or reteplase should be given.
II. Early coronary angiography and revascularization, either by PCI or by CABG
(coronary artery bypass grafting) is the treatment of choice for medium to high risk
patients with NSTEMI.
NOTE : Drug treatment is appropriate in low risk patients with NSTEMI, and coronary
angiography and revascularization reserved for those who fail to settle with drug treatment
(low, medium and high risk patients are categorized in NSTEMI by GRACE score ) .

21. Precaution
Thrombolytic therapy is harmful in NSTEMI.
The aggregate data suggest that patients with NSTEMI may be put at
risk of re-infraction (further heart attack) if thrombolytic therapy is
used

22. Complications and their management in
Myocardial Infraction

23. Complications corrective measures

24. Complications corrective measures

25. Complications corrective measures

26. Complications corrective measures

27. Prognosis of NSTEMI vs STEMI :
NSTEMI
• Short-term (in-hospital or one
month) mortality is lower in
NSTEMI (3-5%),
• Re-infarction rate (further heart
attack) is higher in NSTEMI (15-
25%) after hospital discharge
• Long-term mortality is similar or
higher in NSTEMI.
STEMI
• Short-term (in-hospital or one
month) mortality is higher in
STEMI (10-15%).
• Re-infarction rate (further heart
attack) is lower STEMI (5-8%)
after hospital discharge .
• Long-term mortality in STEMI
(two year mortality is
approximately – 30% in both
cases).