【正文】 racute), ST elevation (acute), ? Q wave, T wave inversion(old) STEMI Laboratory Anterior AMI STEMI Laboratory Inferior AMI STEMI Laboratory Localization LAD STEMI Laboratory STEMI Laboratory Localization LAD STEMI Laboratory Localization LCX STEMI Laboratory Localization RCA [‘reidi?u’nju:klaid]放射性核素 angiography： ： distinct region of disordered contraction, LV function, detection plication examination: blood routine serum cardiac markers STEMI Laboratory marker Range of times to initial elevation （ h） Mean time to peak elevations （ nonthrombolysis ） Time to return to normal range Myoglobin 14 67h 24h cTnI* 36 24h 79d cTnT* 36 12h2d 714d CKMB 36 1624h 34d CKMM 16 12h 38h LDH 810 2448h 1014d Cardiac markers * Most sensitive and specific marker of myocardial damage STEMI Laboratory 敏感的 Changes of cardiac markers STEMI Laboratory Differential diagnosis pectoris： chest pain, plication, general symptoms, elevation of cardia markers, ECG changes pericarditis[.perikɑ:39。daitis]：characteristics[.k230。rikt?39。ristik] of chest pain, time course of chest pain and fever, ECG changes pulmonary embolization[emb?lai39。zei??n]:chest pain, hemoptysis, dyspnea, increased load of RV (SIQIII) STEMI Diagnosis abdominal symptom： acute pancreatitis,cholecystitis, cholelithiasis [ei39。?:tik] dissection： sever chest pain with (tearinglike), radiated to back， with aortic regurgitation[:d?i39。tei??n], CT、 UCG、 MRI、chest Xray Differential diagnosis STEMI Diagnosis ?Before admission: tranfer, make diagnosis within 1020min, initiate reperfusion therapy as soon as possible ?Monitoring and general treatment: CCU ?Reperfusion ?Management of plication ?others STEMI treatment : hemodynamic monitoring, oxygen relief and antiischemia: ?Morphine: 24mg IV ?Nitrates: not use in inferior MI or suspected RV MI with hypotension ?223。blocker: reduce HR, decrease BP, decrease myocardial oxygen consumption, decrease Vf 3. Antiplatelet: ?aspirin： first dosage 300mg， chewing, 100mg/d forever for patients without contraindication ?Clopidogrel: 300mg loading, 75mg/d STEMI treatment : antithrombin, heparin, LMWH of infarct size: reperfusion: ?Fibrinolytic treatment: intravenous， intracoronary ?rtPA： 100mg， in 90 min, use heprin before infusion ?Streptokinase (SK)： 1500,000U， iv in 60min, allergic reaction ?Urokinase (UK)： ,000 U， iv fusion in 30min ?give heprin after intravenous thrombolysis therapy ?Primary Percutaneous Coronary Intervention(PCI) ?CABG STEMI treatment AMI PTCA Stenting STEMI treatment Primary stenting Criteria for thrombolysis in STEMI indication： pain: consistent with AMI changes: ?ST elevation in at least two contiguous leads。 ?new or presumably new LBBB from onset of symptoms ?6hrs： most beneficial ?612hrs： lesser but still important benefits ?12hrs： diminishing benefits but may still be useful in selected patis 70yrs? Absolute contraindication： internal bleeding (excluding menses) 2. Suspected aortic dissection 3. Recent head trauma or known intracranial neoplasm of cerebrovascular accident, known to be hemorrhagic， or ischemic attack within 6 months (including TIA) surgery or trauma within 2 weeks , no response to the treatment . , SBE, suspected atrial thrombosis Criteria for thrombolysis in STEMI Relative contraindication： 180/110mmHg on at least two reading 2. History of chronic, severe hypertension with or without drug therapy peptic ulcer 4. History of cerebrovascular accident bleeding diathesis or current use of anticoagulants or traumatic cardiopulmonary resuscitation hemorrhage retinopathy or other hemorrhage ophthalmic condition exposure to SK or APSAC（ this contraindication is particularly important in the initial 6to 9month period after SK or APSAC administration and applies to reuse of any SKcontaining agent but does not apply to tPA or UK Criteria for thrombolysis in STEMI Judgement of the patency ? Direct： coronary angiography TIMI flow grade 23 ? Indirect： of the elevated ST 50% within 2hrs 2. Relief of chest pain within 2hrs； 3. Reperfusion arrhythmias, within 2hrs：premature ventricular rhythm, accelrated idioventricular rhythm, nonsustained ventricular tachycardia, transient bradycardia, AV block serum cardiac enzyme occurred early, within 14 hrs thrombolysis in STEMI Management of plication ?Ventricular tachycardia： iv lidocaine, amidarone, betablocker ?VF： defibrillation ?bradycardia： atropin, temporary pace maker ： IABP failure： no use of digitalis within 24hrs Special consideration: RV MI with hypotension STEMI treatment Management of right ventricular infarction 50% inferior infarction involve RV； ?Emphasize increase blood volume in inferior AMI patients with hypotension and no LV failure, saline 36L/24h； ?Diuretics is not suitable ?Temporary pacemaker in pts with AVB STEMI treatment ?ACEI： reduce remodelling, mortality, and HF statins: stablize the plaque, improve endothelial[.end?39。θi:li?l] function. ?polarized solution (potassium, magnesium） ?Others: vitamine, FDP ?Routine use of calcium antagonist increase the risk of death in AMI patients STEMI treatment Key concepts ?Atherosclerosis is the leading cause of death and disability, also the main cause of CHD ?Risk factors and prevention of atherosclerosis ?CHD is due to the imbalance between myocardial oxygen supply and demand ?Two large groups of CHD: chronic(stable angina pectoris) and ACS ?ACS posed of UAP/NSTEMI and STEMI, resulting from the plaque rupture or erosion, with differing degree of thrombosis and distal embolization, with different obstruction of the coronary artery. ? reperfusion ei