CASE

A 45 year old male a known case of DM/SHTN came with complaints of

chest pain for 2 hours radiating to left shoulder
C/o palpitation.
C/o sweating.

Vitals: BP -110/60 mmhg

PR -102/mt
Sp02- 99%RA
 INVESTIGATIONS IN MI

• ECG
• Cardiac enzymes (cardiac troponin I&T, CK-MB)
• 2d echo
• CT – Coranary angiogram
• MRI – Coronary angiogram
• Radionuclide scan
 TREATMENT
• Initial management
- oxygen support
- drugs to relief chest pain
• Repurfusion strategy
- Fibrinolysis
-Primary PCI ( percutaneous coronary intervention)
- Integrated repurfusion stratrgy
 PAIN RELIVERS

1. Sub lingual ISDN 5MG /Nitroglycerine 0.4 mg maximum 3

doses at a time of 5 minutes interval.
2. Iv morphine ( 2 to 4 mg ) every 5 minutes maximum 4 to 5
doses.
3. Iv beta blocker (5 mg ) every 2 to 5 mins upto maximum 3
dosage decreases myocardial oxygen demand , and prevents the
reinfarction and ventricular fibrillation.
 LOADING DOSE
All ACS patient should be given loading dosage.

1.ASPIRIN 160 -325mg

2.P2Y12 Inhibitors
- CLOPIDOGREL 300 mg or
-TICAGRELOR 180mg or
- PRASUGREL 60mg
3.ATORVASTATIN 80mg
 FIBRINOLYTICS

• Streptokinase
Dose- 1.5 Million units IV Infusion over 1 hour.
• Reteplase
Dose- 10 million unit bolus followed by other 10 million unit
bolus after 30 minutes.
• Tenecteplase
Dose- 0.5mg/kg iv bolus
Management of heart failure
Heart failure is classified into 2 types
1. Heart failure with preserved Ejection fraction
2. Heart failure with reduced ejection fraction .
( Acute decompensated heart failure).
 CONTRAINDICATIONS FOR
LYSIS
ABSOLUTE CONTRAINDICATION:

-H/o of hemoorhagic stroke

- Ischeamic stroke within past 1 year.

-SBP> 180mmHg

-Active internal bleeding

RELATIVE CONTRAINDICATION:

- Patient on anti coagulants

- peptic ulcer disease

- recent surgery within 2 weeks

-bleeding diastheses
Management of heart failure
Heart failure is of two types .
1. Heart failure with preserved EF
2. Heart failure with reduced EF
( Acute decompensated HF).
Heart failure with preserved EF:
No Durgs have mortality benefits in heart failure with
preserved EF paitents.
ARNI is the only drug have mild mortality benefits.
SGLT 2 inhibitors have mild benefits but still research is going.
Risk factor modification have better mortality benefits.
 ACUTE
DECOMPENSATED HEART FAILURE
Acute decompensated heart failure is managed with
- IV diuretics
-Venodilators/ Vasodilatiors.
- Ionotropes
 DIURETICS
• Loop diuretics
• Iv furosemide given as stat or continuous infusion may be given

• Oral furosemide/ torsemide given to relieve congestion or

volume overload.
• Thiazide diuretics:
• Chlorthalidone , metalozone may be given
 VASODILATIORS
• Nitroglycerin:
• NTG (5 to 200 ug/ min ), decrease pre load and decreases
oxygen demand and releieves pulmonary congestion.
• Nitroprusside:
• Nitroprusside 0.3 ug/ kg/ min to 5ug/kg/min ( both arterial and
venodilators).
• Nesiritide - a recombinant human B type naturietic peptide.
• Serrelaxin - a human recombinant relaxin hormone.
 IONOTROPES
Dopamine - 2 to 20 ug/kg/min
Dobutamine- 2 to 20 ug/kg/min
Milirinone- PDE 3 inhibitors ( 0.3 to 0.7 ug/kg/min)
Levosiminden- dual action both PDE 3 inhibitors and calcium
sensitiser.

Longer duration of Ionotropes increases the risk of arrythymia and

increases the mortality.
 HFrEF
HFrEF patients treated with
ACE -/ARB -/ ARNI
Beta blockers
Aldosterone antagonist
Arteriovenous dilators
Novel drugs
• Patients treated with either ACE inhibitors or ARB inhibitors but never
both
• ARNI. ( Angiotensin receptor and neprilysin inhibitors)
• Sacubitril + valmesartan
• Neprilysin inhibits naturietic peptide,bradykinin, substance p,
angiotensin 1 and 2
 BETA BLOCKERS
Cardio selective beta blockers
1. Metoprolol
2. Carvedilol
3.Bisoprolol.

Beta blockers and ACE inhibitors are started at low dose and
dosage increase every 2 weeks upto
maximum tolerable dose.
RAS activation lead to production of aldosterone
which cause myocardial fibrosis
Spironolactone should be given for patients having
NYHA class 3 and 4 symptoms.
• Arterioveno dilators and digoxin have no mortality
benefits in heart failure patients.