:MYOCARDIAL INFARCTION:

MOHAMMED ATAUR RAHMAN SHAIKH

16111T0013
PHARM.D IIIrd YEAR
PHARMACOTHERAPEUTICS-II
SHADAN COLLEGE OF PHARMACY
Content:
1) Definition.

2) Epidemiology.

3) Causes.

4) Risk factors.

5) Path physiology.

6) Types of MI

7) Signs and Symptoms.

8) Complications.

9) Diagnosis.

10) Management.

11) Prevention.

1) Definition:
Myocardial infarction is the medical name of heart attack.

 A Heart attack is life threatening condition that occurs when blood flow
to the heart muscle is decreased (Ischemia) which causes tissue damage.

 This is usually the result of a blockage in one or more of the coronary

artery.

 A blockage can develop due to a buildup of plaque, a substance mostly

made of fat, cholesterol and cellular waste products.

2) Epidemiology:
 MI is the leading cause of death in US affecting one in five men and one
in sex women.

 4.5 lakhs people die every year due to MI.

 Incidence rates increases with age as do mortality rates due to
infarction.

 Nearly 10% MI occurs in people under 40 years of age and 40% MI

occurs in people above age of 65 years.

 White and blacks are equally affected.

 The survival rate of those hospitalized due to MI has reached

approximately 95% which is due to development of modern medical
technologies.

3) Causes:
Several factors may lead to blockage of arteries.

a) Bad cholesterol:
 Bad cholesterol also called LDL is one of the leading causes of a blockage
in the arteries.
 LDL has a sticking property due to which they get stick to the walls of
arteries and produce plaque (plaque is a hard substance that blocks
blood flow in arteries.
 Blood platelets which help the blood to clot may stick to the plaque and
build up over time.

b) Saturated fats:
 Saturated fats may also contribute to the buildup of plaque in the
coronary arteries.
 These fats may lead to an arterial blockage by increasing the amount of
LDL in blood system and reducing the amount of good cholesterol.

c) Trans fats or Hydrogenated fats:

 Another type of fat that contribute to clogged arteries.
4) Risk factors:
They are classified into two types:

Non-Modifiable:

a)Age: The risk of having a heart attack increases with age.

b) Gender: Males are at higher risk than females.

c) Family history: You’re more likely to have a heart attack if you have a
family history of early heart disease.

d) Genetic abnormalities.

Modifiable:

a) Hypertension: You’re at greater risk for heart attack if you have high
blood pressure. Having high blood pressure damages your arteries and
accelerates the buildup of plaque.

b) DM: High blood sugar levels can damage blood vessels and eventually lead
to coronary artery disease. This is a serious health condition that can trigger
heart attacks in some people.

c) Hypercholesterolemia: High cholesterol specially LDL is a leading cause

of blockage in the arteries.

d) Dietary habits: Eating foods rich in cholesterol and fats increases the risk
of heart attack.

e) Obesity and physical inactivity:

People who have excess body fat are more likely to develop heart disease
even they have no other risk factors.

f) Alcohol consumption: Acute and prolonged intake of high quantities of

alcoholic drinks (3-4 or more) increases the risk of heart attack.
g) Smoking: Increases a person’s risk for heart disease to about 4 times
greater than non smokers.

h) Stress: increases the chances of heart attack.

 Use of illegal drugs including cocaine and amphetamine increases the
chances of heart attack.

5) Path physiology:
Coronary arterial occlusion:

 Atherosclerotic plaque formation.

 Rupture of high risk atherosclerotic plaque in the coronary arteries is a
primary Causative factor in the development of MI.
 When exposed to sub endothelial collagen and necrotic plaque contents,
platelets adhere, become activated, and release their granule contents
and aggregate to form micro thrombi.
 Vasospasm is stimulated by mediators released from platelets.
 Tissue factor activates the coagulation pathway adding the bulk of the
thrombus.
 Within minutes the thrombus expands to completely occlude the vessel
lumen.
Myocardial response:

 Coronary arterial obstruction diminishes blood flow to a region of

myocardium causing ischemia, rapid myocardial dysfunction and
eventually with prolong vascular compromise –myocyte death.

 The anatomic region supplied by that artery is referred as the area at

risk.
6) Types of MI:
The two main types of MI based on pathophysiology are:

1) Transmural infarction:
 Transmural infarction extends throughout the whole thickness of the
heart muscle.

 Occurs usually as a result of complete occlusion of the blood supply to

the heart muscles.

 It is also known as ST Elevation Myocardial Infarction (STEMI).

2) Subendocardial infarction:
 Involves a small area in the subendocardial wall of the left ventricle,
ventricular septum or papillary muscles.

 It is also known as Non ST Elevation Myocardial Infarction (NSTEMI) and

also Non transmural infarction.
7) Signs and symptoms:
 Signs and symptoms are unique to each individual patient.

 Ranging from no symptoms to sudden cardiac arrest.

1) Pressure, tightness, pain or squeezing or aching of sensation in your chest or

Arms that may spread to neck jaw or Back.

2) Nausea and vomiting results as reflex from severe pain.

3) Heartburn or abdominal pain.

4) Shortness of breath.

5) Cold sweat.

6) Fatigue.

7) Light headedness.

8) Palpitation.

9) Anxiety and dizziness.

8)Complications :
 Sudden death.
 Disturbance of rate, rhythm and conduction.
 Cardiogenic shock.
 Heart failure.
 Angina pectoris.
 Cardiac rupture.
 Thromboembolism.
 Ventricular septal defect.
 Ventricular anuerysm.
 Pericarditis .
 Shoulder hand syndrome.
 Psycological problems.
 Depression .
9)Diagnosis:
The diagnosis of heart attack is based on symptoms,ECG and the results of
blood studies.

12-Lead ECG:
 This is one of the initial test that will be done .

 Frequently paramedics will do this on site or on the way to the hospital.

 It helps to know what type of heart attack and where it has occurred.

 Heart rates and rhythm can be monitered.

Blood studies:
By measuring the levels of biomarkers like creatine phosphokinase and
troponin ,the doctor can determine size of the heart attack and approximately
when the heart attack.

Echo cardiogram:
 Echocardiogram can be used during and after a heart attack to learn
about how the heart is pumping and identify what areas of the heart are
not pumping properly.

 The Echo is also helps in knowing if any structure of the heart(valves,

septum etc…) have been injured during heart attack.

Cardiac catheterization:
 Cath may be performed during the first hours of heart attack if
medications are not relieving the ischemia or symptoms.

 The cardiac cath can be used to directly visualize the blocked artery and
guide the choice for which procedure (such as angioplasty, stent
placement, or coronary artery bypass surgery) may follow.
Angiography:
 To detect % of blockage and type of MI.

Chest X-ray .

10)Management:
 The main goal of therapy are to breakup or prevent clots,prevent
platelet from gathering and sticking to the plaque,stabilise the plaque
and prevent further ischemia.

 General treatment for MI include MONA therapy:

M=Morphine

O=Oxygen

N=Nitro glycerin

A=Aspirin

Supportive care;
1)Defibrillation:
 Using an electrical shock to correct a rapid, irregular heart beat and
restore the hearts normal rhythm.


2)Oxygen therapy:
 Providing the extra oxygen to the lungs of people with shortness of
breath.
 DRUGS DOSE(mg) ACTION ADRs
1)ANTIIPLATELETS: They inhibit platelet Nausea, vomiting,
ASPIRIN 75-325mg aggregation and control epigastric distress, blood
VAROPAXAL 2-8mg intravascular thrombus in stool, peptic
CLOPIDOGREL 75-300mg formation. ulceration.

2)ANTITHROMBOTIC Prevent the formation of Back pain, nausea,

AGENTS: 250mg thrombi associated with MI hemorrhage, headache,
BIVALURIDIN 100mg/ml and inhibit platelet function. and hypotension.
ENOXAPARIN 120mg
DALTEPARIN

3)VASODILATORS: Relieve chest discomfort by Nausea, vomiting,

NITROGLYCERIN 2.5-6.5mg improving myocardial oxygen edema, dizziness,
supply by directly acting as headache.
arteriolar vasodilator.

4)BETA-BLOCKERS: Decreases the heart rate and Tiredness ,reduced

METOPROLOL 50-500mg cardiac output as a result exercise
ATENOLOL 25-100mg cardiac work is reduced. tolerance,bradycardia.
BISOPROLOL 5-20mg

5)ACE INHIBITORS: Block the conversion of Dry cough, rashes, taste

CAPTOPRIL 50-150mg angiotensin-I to angiotensin- disturbance, renal
ENALAPRIL 2.5-40mg II by inhibiting ACE. failure and angioedema.
LISINOPRIL 10-40mg

6)THROMBOLYTICS: Lyses the thrombi or clot to Pulmonary edema,

ALTEPLASE 2-100mg recanalize occluded blood bleeding, hypotension,
TENERTIPLASE 30-50mg vessel. hemorrhage, fever.

7)ANALGESICS: They relieve pain by acting Nausea, vomiting,

MORPHINE 2-4mg on the CNS or peripheral mucosal damage.
pain mechanism without
altering unconsciousness.
Medical procedures:
1) Coronary stent:

 A tube is placed in the arteries of the heart to keep them open.

2) Coronary angioplasty:

 Unblocking an artery by inflating a balloon inside it.

 A stent may also be inserted to hold the artery.

Surgery:
Coronary Artery Bypass Grafting (CABG):

 Coronary artery bypass graft is a surgical procedure to restore normal

blood flow to an obstructed coronary artery. A normal coronary artery
 transports blood to and from the heart muscle itself, not through the
main circulatory system.

 There are two main approaches.

 In one, the left internal thoracic artery is Diverted to the left anterior
descending branch of the left coronary artery.

 In the other, a great saphenous vein is removed from a leg; one end is
attached to the aorta or one of its major branches, and the other end is
attached to the obstructed artery immediately after the obstruction to
restore blood flow.
11)Preventions:
 Avoid excess salt intake.

 Avoid foods rich in cholesterol and fats.

 Smoking cessation.

 Avoid alcohol consumption.

 Do regular exercise.

 Eat healthy diet.

 Maintain the body weight.

 Avoid using illegal drugs.

References:
1. Lippincott Williams & Wilkins (LWW) - an imprint of Wolters Kluwer -
publishes scientific, technical, and medical content.
2. J. T. DiPiro, T. L. Schwinghammer, B. Wells (eds.), Pharmacotherapy: A
Path physiologic Approach, 5th ed., Appleton & Lange, Stamford, CT,
2002.
3. Roger Walker and Clive Edwards, Clinical Pharmacy and Therapeutics
(3rd Edition) London: Churchill Livingstone, 2003.
4. https://en.wikipedia.org/wiki/Myocardial_infarction
5. https://www.healthline.com/health/acute-myocardial-infarcyion

6. Davidson’s principles and practice of medicine (Book, 2014)