OSCE NOTES for MYOCARDIAL INFARCTION

MYOCARDIAL INFARCTION
- Or Acute Myocardial Infarction is the interruption of blood supply to part of the heart, causing some heart cells to die.
- Either one of the following criteria satisfies the diagnosis for an acute, evolving, or recent MI
o Typical rise and gradual fall (troponin) or more rapid rise and fall (CK-MB) of biochemical markers of myocardial
necrosis with at least on of the following:
Ischemic symptoms
Development of pathologic Q waves on the ECG
ECG changes indicative of ischemia (ST segment elevation or depression)
Coronary artery intervention (e.g., coronary angioplasty)
o Pathological findings of an acute MI
CHIEF COMPLAINT: Chest pain
HISTORY
- Key findings:
o Heavy, squeezing, choking, or smothering pain as if someone is sitting on my chest
o Pain localized at the back of the sternum (substernal) and/or the epigastrium, radiating to the arms, abdomen, back,
lower jaw, and neck
o Prolonged pain unrelieved by rest or sublingual nitroglycerin
o Pain is of recent onset (within prior 2 weeks)
- Other associated findings:
o Weakness
o Anxiety
o Sense of impending doom
o Nausea and vomiting (GI complaints are believed to be related to the severity of the pain and the resulting vagal
stimulation)
PHYSICAL EXAMINATION
- General Survey
o Anxious and restless, attempting unsuccessfully to relieve pain by moving about in bed, altering their position, and
stretching
- Vital Signs

OSCE NOTES for MYOCARDIAL INFARCTION

o Temperature elevations up to 38C (may be observed during first week after STEMI)
o May have increased blood pressure due to anxiety or decreased blood pressure due to heart failure
- Skin
o Pale and cool
o Diaphoresis
- Respiratory
o Breathing maybe labored and rapid.
o Fine crackles, coarse crackles, or ronchi may be heard when auscultating the lungs
- Cardio
o May be bradycardic and/or hypotensive due to parasympathetic hyperactivity
o May be tachycardic and/or hypertensive due to sympathetic hyperactivity
o Abnormalities of the precordial pulsations such as lack of PMI or presence of diffuse contractions when patient is
placed in the left lateral decubitus position
o First heart sound may be diminished as result of decreased contractility
o Fourth and Third heart sound maybe present
o Transient midsystolic or late systolic apical murmurs (due to dysfunction of the mitral valve apparatus)
o Decreased carotid pulse (reduced stroke volume)
o Pericardial friction rub after 48-72 hours
o Jugular vein distension, peripheral edema, and an elevated CVP in patients with right ventricular infarcts
- Extremities
o Pallor associated with perspiration and coolness of the extremities
DIAGNOSIS
- Non-ST Elevation ACS (NSTE-ACS)
o 12-Lead ECG
ST-segment depression
Transient ST-segment elevation
T wave inversion
o Cardiac Biomarkers (Troponin and CK-MB)
Elevated levels
Rising and/or falling pattern of Troponin I or T (obtained at presentation and 3-6 hours after onset of symptom)
Timing of cardiac markers
Cardiac Biomarker
Time of detection
Peak
Duration

OSCE NOTES for MYOCARDIAL INFARCTION

Troponin-T
3-12 hours
24 hours
Troponin- I
3-12 hours
24 hours
CK-MB
4-8 hours
24 hours
- ST-Elevation Myocardial Infarction (STEMI)
o 12-Lead ECG
Classification
Timing
ECG Findings
Acute MI
Minutes to hours
ST elevation + peaked or inverted T waves
+ Q waves
Recent MI
Hours to days
Q waves + ST elevation + T wave
inversion
Old MI
Days to months
Q waves + Isoelectric segment + T wave
inversion
o
Class
Class I
Class II

Class III

Class IV

Killip Scoring for STEMI

Description
- No rales or signs of pulmonary venous
congestion
- Normal BP
- Moderate heart failure, bibasal rales
- Normal BP
- S3 gallop
- Tachypnea or signs of right-sided CHF
(venous & hepatic congestion)
- Severe heart failure
- (+) Mid basal rales and pulmonary edema
- (+) S3 and S4
- Normal BP
- Shock with SBP <90mmHg and evidence of
peripheral vasoconstriction
- Peripheral cyanosis
- Mental confusion and oliguria

5-14 days
5-10 days
2-3 days

Risk of Mortality
0-5%
10-20%

35-45%

85-95%

OSCE NOTES for MYOCARDIAL INFARCTION

DIFFERENTIAL DIAGNOSIS
- Differential diagnosis for chest pain, characteristic symptom for myocardial infarction, includes that of cardiac, vascular,
pulmonary, GIT, and musculoskeletal origin.
Condition
Duration of Pain
Quality
Location
Associated Features
Unstable Angina
10-20 minutes
Pressure, tightness,
Retrosternal
Precipitated by
(Cardiac)
squeezing, heaviness,
Radiation to neck, jaw,
exertion, exposure to
burning
shoulders, or left arm
cold, psychologic
stress
Pulmonary Embolism
Sudden onset
Pleuritic
Often unilateral, on the
Dyspnea, tachypnea,
(Vascular)
side of embolus
tachycardia,
hypotension
Pneumonia or Pleuritis
Variable
Pleuritic
Unilateral, often localized Dyspnea, cough,
(Pulmonary)
fever, rales,
occasional pleural
friction rub
Esophageal reflux
10-60 mins
Burning
Substernal, epigastric
Worsened by
(Gastrointestinal)
postprandial
recumbency
Relieved by antacids
Costochnodritis
Variable
Aching
Sternal
May be reproduced by
(Musculoskeletal)
localized or pinpoint
pressure on exam
PROGNOSIS
- TIMI score for NSTE-ACS
Components
Age > 65 years
> 3 CAD risk factors
Known CAD (> 50% stenosis)
Aspirin use in the past 7 days

Points
1 point
1 point
1 point
1 point

Interpretation
Risk Total Score:
0-7 points
High Risk Score:

OSCE NOTES for MYOCARDIAL INFARCTION

Severe angina in last 24 hours

Elevated cardiac markers
ST deviation >0.5 mm
- TIMI score for STEMI
Components
HISTORICAL
Age 65-74 years
Age > 75 years
DM, hypertension, angina
EXAMINATION
Systolic BP <100mmHg
Heart rate >100 bpm
Killip II-IV
Weight <67 kg
PRESENTATION
Anterior ST elevation or LBBB
on ECG
Time to treatment > 4hrs

1 point
1 point
1 point

>3 points (13% mortality)

Points

Interpretation
Risk Total Score:
014 points

2 points
3 points
1 point

High Risk Score:

>5 points (12% mortality)

3 points
2 points
2 points
1 point
1 point
1 point

MANAGEMENT AND TREATMENT

- NSTE-ACS
o Standard and Anti-Ischemic Therapy
Bed rest with continuous ECG monitoring
Supplemental oxygen if O2 sat <94%
Nitrates
Sublingual nitrate (ISDN 5mg/tab) q5 mins x total of 3 doses
IV NTG in first 48 hours (5-10mcg/kg/min) for persistent ischemia, heart failure, or hypertension
Avoid in:
o Hypotensive
o Bradycardic
o Suspected with RV infarction
o Received sildenafil for the past 24 hours

OSCE NOTES for MYOCARDIAL INFARCTION

Beta Blockers
Start within first 24 hours
Metoprolol succinate
Carvedilol
Bisoprolol
Avoid in:
o Signs of acute heart failure
o Low output states
o PR interval > 0.24 seconds, 2nd or 3rd degree AVB without pacemaker
o Active asthma or reactive airway disease
Anti-Platelet Therapy
Initial treatment should begin with aspirin
In the absence of a high risk of bleeding, patient should also receive a P2Y 12 inhibitor for upto 12 months
Clopidogrel
Ticagrelor
Prasugrel
Anti-Coagulant
Unfractionated Heparin (Mainstay treatment)
Target aPTT 50-70 sec (ratio of 1.5-2.5)
Dose: 60U/Kg IV bolus (max of 4,000 units), then 12 U/Kg infusion (1000 units/hr) for 48 hours or until
PCI is performed
Enoxaparin
Dose: 30 mg IV loading dose, then 1 mg/kg SC q12 for the duration of hospitalization or until PCI is
performed
Fondaparinux
Dose: 2.5 mg SC OD for duration of hospitalization or until PCI is performed
Note:
Conservative Medical Management
For low risk patient
Anti-ischemic therapy and antithrombotic therapy followed by close observation
Early Invasive Management (Revascularization)

OSCE NOTES for MYOCARDIAL INFARCTION

For high risk patient

Done after treatment with anti-ischemic and anti-thrombotic agents
Angiography carried out with 48 hours
Coronary revascularization (PCI or CABG)

Conservative Medical Management

Low risk score
Troponin-negative female patients
Patient or physician preference in the absence of highrisk features

Early Invasive Management

Recurrent angina or ischemia at rest or with low-level
activities despite intensive medical therapy
Elevated cardiac biomarkers
New or presumably new ST segment depression
CHF symptoms, rales, MR
Reduced left ventricular function
Sustained ventricular tachycardia
PCI <6 months or prior CABG
High-risk findings from noninvasive testing
Hemodynamic instability
Mild-to-moderate renal dysfunction
Diabetes mellitus
High TIMI risk score >3

STEMI
o Prehospital Management of STEMI
Recognition of symptoms
Rapid deployment of an emergency medical team capable of performing resuscitative maneuvers
Expeditious transportation
Expeditious implementation of reperfusion therapy
o Reperfusion Therapy: PRIMARY GOAL OF MANAGEMENT

OSCE NOTES for MYOCARDIAL INFARCTION

Reperfusion therapy (fibrinolysis or PCI) should be administered to all eligible patients with STEMI with
symptom onset within the last 12 hours
Primary PCI: recommended method of reperfusion when it can be performed in a timely fashion
Fibrinolysis: administered at Non-PCI-capable centers

Fibirnolysis/Thrombolysis
Generally Preferred if:
- Early presentation (<3 hours of symptom onset)
- Invasive strategy is not available
- Delay to invasive strategy
a. Prolonged transport
b. Door-to-balloon minus door-to-needle time >1 hr
c. Medical contact-to-balloon or door-to-balloon time >
90 minutes
Fibrinolytic Agents
- Streptokinase
- Tissue plasminogen activators
Adjunctive anti-platelet therapy with fibrinolysis
- Aspirin continued indefinitely
- Clopidogrel for at least 14 days up to 1 year
Adjunctive anticoagulant therapy with fibrinolysis: given for a
minimum of 48 hours or until revascularization is performed
- Unfractionated heparin
- Enoxaparin
- Fondaparinux

Invasive Strategy (PCI)

Generally Preferred if:
- Available PCI lab with surgical back-up
a. Medical contact-to-balloon or door-to-balloon time >
90 minutes
b. Door-to-balloon minus door-to-needle time <1 hr
- High risk STEMI
- Contraindications to fibrinolysis
- Late presentation (symptom onset >3 hours)
- Diagnosis of STEMI is in doubt
Percutaneous coronary intervention (PCI) or percutaneous
transmural coronary angioplasty (PTCA): balloon angioplasty and
stenting
Antiplatelet therapy during Primary PCI
- Aspirin indefinitely after PCI
- One P2Y12-receptor inhibitor continued for 1 year for
those who receive a stent:
a. Clopidogrel
b. Prasugrel
c. Ticagrelor

Anticoagulant therapy during primary PCI:

- UFH
- Bivalirudin
Fibrinolysis is still reasonable if symptom onset is within 12-24 hours as long as there is evidence of ongoing ischemia

OSCE NOTES for MYOCARDIAL INFARCTION

Supportive Care
o Activity
First 12 hours: bed rest
Next 12 hours: dangling of feet at bedside and sitting in a chair
2nd and 3rd day: ambulation in the room with increasing duration and frequency to a goal of 185 m at least 3x a
day
2 weeks: resumption of work and sexual activity
o Diet
Nothing or only clear liquids for the first 4-12 hours
Use of stool softener
o Sedation
Many require sedation during hospitalization to withstand period of enforced inactivity
Secondary Prevention and Long Term Management
o Smoking
Complete cessation
o BP control
BP <140/90 or <130/80 if CKD or DM
o Lipid Management
High dose statins
<7% of total calories as saturated fats and <200mg/day total cholesterom
o Physical Activity
30 minutes of moderate intensity aerobic exercise, 3-4 days per week
o Weight management
BMI 18.5-24.9 kg/m2
Waist circumference: women <35 inches, men <40 inches
o DM Management
HBA1c <7%
o Antiplatelets
Aspririn or P2Y12-receptor inhibitors
o RAAS Blockers

OSCE NOTES for MYOCARDIAL INFARCTION

ACEI in stable high risk patients (Anterior MI, previous MI, Killip >, II, EF<40%)
Beta Blockers
Continued indefinitely