Josephine Holt, Celine Goh, Panayioti Kissias, Marcus Chan

and Matthew Willett

Give aspirin 300mg (if not given by paramedics/GP)
Give morphine 5-10mg IV
Give anti-emetic e.g. metoclopramide 10mg IV
Give oxygen if sats <95% or breathless or in acute LVF (see ECG)

Send off to Primary PCI

An injectable anticoagulant must be used in primary PCI. Bivalirubin (thrombin inhibitor) is
preferred.
Patient W.S. had a stent put in his right posterior descending artery (completely blocked) but
not the L.A.D. (only slightly blocked)
Stents
A drug-eluting stent was used which prevents endothelialisation and cell proliferation (that
might lead to cancer)
 Royal Free Hospital
Heart Attack Centre
Admission Process

Routine GTN use

now not
recommended in
the acute setting
unless patient is
hypertensive or in
acute LVF.
Patient goes to CCU.

To prevent in-stent thrombosis, patients who undergo PCI must take one or more blood-
thinning drugs after the procedure.

Patient W.S. was prescribed:

Reducing platelet aggregation
Aspirin (COX Inhibitor)
Ticagrelor (Approved 2010, interrupts purinergic signaling)
Reducing the work of the heart
Bisoprolol (Beta-blocker)
Secondary prevention
Ramipril (ACE inhibitor)
Atorvastatin (Statin)
 Postoperative Assessment ABCDE
Airway
Open: patient is verbal

Breathing
O2 saturation 99%

Circulation
RR 16 times/min
BP hypotensive

Disability
Glasgow Coma Scale 15/15

Examination
Blood sugar within normal range (6.8 mmol/L)
 Symptoms of ischaemia
Silent infarcts

The ECG
Cardiac enzymes
Troponin

Angiography
 Symptoms of ischaemia
Silent infarcts

The ECG
Cardiac enzymes
Troponin

Angiography
 ECG
Records the rhythm and electrical and muscular functions of the heart.
Normal ECG trace:
 ECG
In an acute STEMI, the ECG trace changes according to time

A) Normal B) Hours C) Days D) Weeks E) Months

 ECG
12-lead ECG has 10 electrodes:
Leads represent the electrical potential difference between two points
I, II, III limb leads
aVR, aVL, aVF augmented limb leads
V1 V6 chest leads

ST segment elevation localises to ECG leads of the

affected myocardium
 ECG
Localisation
Anterior

Anterior

LAD
 ECG
Localisation
Anterior

Anterior

Inferior LAD

Right Coronary
artery (RCA)

Left circumflex
Inferior
artery (LCx)
 ECG
Localisation
Lateral Anterior

Anterior

Inferior Lateral LAD

Lateral
Right Coronary
artery (RCA) LCx or diagonal from
LAD
Left circumflex
Inferior
artery (LCx)
 ECG
ST elevation >1mm in 2 or more contiguous limb leads, ST elevation >2mm in 2 or more
chest leads
Posterior STEMI frequently has ST depression in V1-V3 instead of elevation since the
vectors are completely reversed
20% may have normal ECG
 Angiography
X-ray image of blood vessels after they are filled with a contrast material
Can visualise the branches of both the right and left coronary arteries
Can identify the exact location in a coronary artery where an occlusion is present
 Angiography
1) Performed under local anaesthetic
2) Insertion of small catheter into artery in groin or arm
3) Catheter is fed up to the opening of the coronary arteries
4) Radiographic contrast is injected into each coronary artery
5) The images are processed as angiograms
ST-Elevation in Inferior Leads (II, III, aVF) RCA Infarct
ST-Depression in Anteroseptal Leads (V2-V4) Ischaemia, possible LAD involvement
 Observe coronary arterial flow to assess severity of arterial occlusion
LCA: Right Anterior Oblique (RAO) and Postero-Anterior (PA)
RCA: Left Anterior Oblique (LAO)
Cranial, Caudal or Straight

RAO Caudal

LAO Straight

AP Straight
 Left Coronary Artery
Left Main Stem
Left Anterior Descending
Main Circumflex
Obtuse Marginals (PLCx)

Right Coronary Artery

Acute Marginal
Posterior Descending

Taken from:
http://www.intechopen.com/books/ischemic-heart-disease/introduction-to-ischemic-heart-disease
 RCA with Stent (no balloon, with
RCA with Stent (balloon, no contrast)
contrast)
 RCA with Stent (no balloon, with
RCA with Stent (balloon, no contrast)
contrast)
Inferior ST Elevation less pronounced
Anteroseptal ST-Depression still persistent to be managed via medical intervention.
1) Assessment of risk factors of secondary MI:

Non modifiable Modifiable

Age Smoking

Male Hypertension

FH (1st deg. Relative <55yrs) DM

Hyperlipidemia

Obesity

Sedentary lifestyle
2) Cardiac Rehab

NICE: All patients (regardless of their

age) should be given advice about and
offered a cardiac rehabilitation
programme with an exercise
component.
3) Lifestyle changes
Diet Mediterranean
Physical activity
Smoking cessation
Alcohol consumption
Weight control
4) Drug therapy
Dual antiplatelet therapy

Aspirin (75mg)
Clopidogrel
Beta blocker (e.g. Bisoprolol 2.5-5mg/d)
ACE inhib.
Statin (e.g. simvastatin 40mg)
5) Reviews

5 weeks post MI

Symptom review
Angiography?

3 months post MI

Fasting lipids
Thank you for listening!