treat cordially
The main purpose of the treatment of acute myocardial infarction is to restore myocardial blood perfusion, save dying myocardium, prevent infarction from expanding or narrowing the range of myocardial ischemia, protect and maintain cardiac function, deal with serious complications in time, and prevent sudden death, so that patients can not only survive the acute phase safely, but also maintain as many functional myocardium as possible after rehabilitation.
Treatment cycle
Acute hospitalization requires long-term maintenance treatment.
Emergency treatment
Rest, hospitalization, bed rest in acute stage.
Monitor and closely observe the changes of heart rate, heart rhythm, blood pressure and cardiac function, and take timely treatment measures.
Oxygen inhalation, for those with dyspnea and decreased oxygen saturation, intermittent or continuous oxygen inhalation through nasal catheter mask in the first few days is helpful to maintain oxygen supply when cardiac function declines.
Nursing, establishing venous access, and keeping the route of administration unblocked. Patients in acute phase should stay in bed 12 hours. If there are no complications, patients should be encouraged to stay in bed for 24 hours for physical activity. If the situation permits, you can walk in the ward on the third day, and gradually increase the activity from 4 to 5 days after infarction until you walk100 ~150m every day for three times.
In case of contact pain, besides sublingual administration or intravenous drip of nitroglycerin, morphine and other analgesic drugs can also be used to relieve the pain.
medicine
Morphine or pethidine
Intravenous injection of morphine or intramuscular injection of pethidine can relieve patients' sense of dying and excessive tension.
glonoin
Dilate coronary artery and increase blood flow. Patients with right ventricular inferior wall infarction or obvious hypotension are not suitable for application.
Beta receptor blocker
Beta blockers include propranolol, metoprolol and labetalol. Metoprolol can reduce myocardial oxygen consumption, improve oxygen supply in ischemic area, reduce infarct area and reduce recurrent malignant arrhythmia such as myocardial ischemia, reinfarction and ventricular fibrillation. Severe heart failure, low cardiac output, increased risk of cardiogenic shock, age greater than 70 years, systolic blood pressure less than 120mmHg, sinus tachycardia greater than 1 10 beats/min or heart rate less than 60 beats/min, prolonged myocardial infarction time, second or third degree atrioventricular block, PR interval greater than 0.24 seconds, etc.
Antiplatelet drugs
Aspirin and clopidogrel were used in combination, and the maintenance dose was given after oral loading dose of antiplatelet drugs. Inhibiting platelet aggregation and preventing thrombosis from forming again is also a common drug combination that needs to be taken for a long time after stent implantation to prevent the recurrence of myocardial infarction.
anticoagulant
Anticoagulation can establish and maintain the patency of infarct-related blood vessels, and can prevent deep vein thrombosis, pulmonary embolism and intraventricular thrombosis. For patients receiving thrombolysis or unplanned reperfusion therapy, fondaparinux sodium is beneficial to reduce mortality and reinfarction rate without increasing bleeding complications.
Captopril or irbesartan
It is helpful to improve myocardial remodeling in recovery period and reduce the mortality of myocardial infarction and the occurrence of heart failure. Patients with bilateral renal artery stenosis and pregnant women are prohibited. If you can't tolerate captopril, you can consider irbesartan. The combination of these two drugs is not recommended. For patients who can tolerate captopril, it is not recommended to replace captopril with irbesartan. ACEI includes captopril, enalapril, perindopril, benazepril, etc.
Statins
Statins can effectively reduce serum total cholesterol and very low density lipoprotein, delay the progression of plaque and stabilize plaque. Statins should be used regardless of blood lipid level, including simvastatin, fluvastatin, atorvastatin, pravastatin and rosuvastatin. Statins are safe, and liver function should be tested when they are used.
Antiarrhythmic drugs
Arrhythmia must be eliminated in time to avoid serious arrhythmia or even sudden death. If ventricular fibrillation or persistent polymorphic ventricular tachycardia occurs, asynchronous DC defibrillation or synchronous DC cardioversion should be performed as soon as possible. Lidocaine should be used immediately once ventricular premature beats or ventricular tachycardia are found. Ventricular arrhythmia can be repeatedly treated with amiodarone. Atropine can be used for bradyarrhythmia. If the atrioventricular block develops to the second or third degree, accompanied by hemodynamic changes, it is suggested to temporarily pace with an artificial pacemaker and take it out after the conduction disorder disappears. Verapamil, metoprolol and amiodarone are commonly used for supraventricular tachyarrhythmia. If the drug cannot be controlled, synchronous DC cardioversion should be considered.
Surgical therapy
It is one of the most important treatment measures for acute myocardial infarction to open the occluded coronary artery within 3~6 hours from the onset of the disease, at most within 12 hours, so as to make the myocardium reperfusion, save the dying myocardium or narrow the scope of myocardial infarction, and reduce the myocardial remodeling after infarction.
Percutaneous coronary intervention
If the patient is in an ambulance or a hospital without percutaneous coronary intervention, but it is expected that he can be transferred to a qualified hospital within 120 minutes and complete percutaneous coronary intervention, the direct percutaneous coronary intervention strategy will be preferred and the reperfusion will be completed within 90 minutes; Or if the patient is in a hospital where percutaneous coronary intervention is feasible, the reperfusion should be completed within 60 minutes.
Direct percutaneous coronary intervention
Indications are patients with persistent new ST segment elevation or new left bundle branch block within 12 hours after symptom onset. If the patient still has chest pain and ECG changes within 12~48 hours, he can also receive interventional therapy as soon as possible.
Remedial percutaneous coronary intervention
If there is still obvious chest pain after thrombolytic therapy, and the elevated st segment is not significantly reduced, coronary angiography should be performed as soon as possible. If the artery is not recanalized, it is suggested to implement percutaneous coronary intervention immediately.
Percutaneous coronary intervention in patients with recanalization after thrombolytic therapy
After successful thrombolysis, emergency angiography and revascularization of infarct-related arteries can alleviate myocardial ischemia caused by severe residual stenosis and reduce the occurrence of reinfarction. After successful thrombolysis, stable patients received remedial percutaneous coronary intervention.
Thrombolytic therapy
If the time of direct percutaneous coronary intervention is expected to exceed 120 minutes, thrombolytic strategy should be the first choice, and thrombolytic drugs should be given to patients at 10 minutes.
indicate
ST segment elevation in two or more adjacent leads, or the history suggests that acute myocardial infarction with left bundle branch block, the onset time is less than 12 hours, and the patient is younger than 75 years old. Patients with myocardial infarction with significantly elevated ST segment are older than 75 years old. After carefully weighing the pros and cons, the onset time of myocardial infarction has reached 12 or 24 hours, but patients with progressive ischemic chest pain and extensive st segment elevation can also be considered.
Taboo symptom
Hemorrhagic stroke has occurred before, ischemic stroke or cerebrovascular event has occurred within 6 months. Central nervous system injury, intracranial tumor or deformity. Active visceral bleeding occurred in the last two weeks, and aortic dissection was not ruled out. Severe and uncontrolled hypertension at admission is greater than180/110mmhg or chronic severe hypertension. At present, anticoagulants with therapeutic dosage are being used or have a known bleeding tendency, and they have a history of external injuries in the last 2 weeks, including head trauma, traumatic cardiopulmonary resuscitation or cardiopulmonary resuscitation for more than 10 minutes. I had an operation in HKUST in the last three weeks, and I had a puncture in the incompressible big blood vessel in the last two weeks.
Emergency coronary artery bypass grafting
If interventional therapy or thrombolytic therapy fails, emergency coronary artery bypass grafting should be performed within 6-8 hours, but the mortality rate is significantly higher than that of elective coronary artery bypass grafting.
Mode of operation
Take the patient's own blood vessels, connect the distal end of the narrow coronary artery with the aorta, let the blood bypass the narrow part and reach the ischemic part, and improve the blood supply to the myocardium.