Internal illnesses. Cardiac ischemia. Myocardial infarction (most important)

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Internal illnesses. Cardiac ischemia. Myocardial infarction (most important)

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17. ISCHEMIC HEART DISEASE. MYOCARDIAL INFARCTION

Pathogenesis. With myocardial infarction, insufficient blood supply to the myocardium occurs with the development of lesions and necrosis in it.

Clinic. The first period of myocardial infarction represents the period of precursors (prodromal). New-onset angina may occur, the most acute period lasts up to 2 hours. The duration of the acute period is up to 8-10 days, the following course options are available:

1) anginal (pain behind the sternum for more than 20 minutes), motor restlessness, cold sticky sweat, nausea and vomiting;

2) gastralgic (pain in the epigastric region);

3) asthmatic (acute left ventricular failure);

4) arrhythmic (acute rhythm disturbances);

5) cerebral (insufficiency of cerebral circulation);

6) asymptomatic (lack of clinical manifestations).

This is followed by a subacute period lasting up to 4-8 weeks. Then a post-infarction period develops, lasting up to 2-6 weeks.

The pain syndrome differs in intensity, duration (from several hours to a day or more). The pain has a pressing, compressive, cutting, tearing character, is localized more often behind the sternum, less often captures the entire anterior chest wall. The pain radiates to the left shoulder, arm, sometimes jaw, epigastric region, is not removed by nitroglycerin, sometimes by drugs. Patients are excited, experience fear of death. The skin is pale, the mucous membranes are cyanotic, bradycardia develops, more often moderate tachycardia, a short-term increase in blood pressure. Heart sounds are weakened, a proto-diastolic gallop rhythm can be heard.

Diagnostic study. Manifestations of resorption-necrotic syndrome are noted (an increase in the level of leukocytes in prephyseal blood on the first day, after 2-3 days an increase in ESR with a gradual decrease in the number of leukocytes).

The levels of transaminases specific for myocardial infarction are studied: myoglobin, microfraction of creatine kinase (MB-CK mass) - early markers of myocarditis damage; troponin, microfraction of creatine kinase (CF-CK) - late markers of myocarditis damage. It is necessary to take into account the de Ritis coefficient (AST/ALT ratio), which increases to more than 1,33 with myocardial damage.

In myocardial infarction, an ECG study shows a pathological Q wave with a depth of more than 1/3 R and a width of more than 0,03, there is a shift in the ST interval upward from the isoline and negative T.

Treatment. Pain relief is carried out with narcotic analgesics, fentanyl with droperidol, nitrous oxide anesthesia, and epidural anesthesia.

If the pain syndrome lasts less than 6 hours, thrombolytic and anticoagulant therapy is performed.

Nitrates, β-blockers are used to prevent an increase in the necrosis zone.

In the subacute period, long-acting nitrates, indirect anticoagulants are used to strengthen the coronary circulation.

Flow. It can be uncomplicated, complicated, protracted and recurrent.

Forecast. In the absence of complications, the prognosis is favorable, and in case of complications, it is serious.

Author: Myshkina A.K.

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