【正文】 boratory,Localization LCX,第九十六頁，共一百一十五頁。,STEMI,Laboratory,Localization RCA,第九十七頁，共一百一十五頁。,2.vectorcardiography 3.radionuclide angiography： 4.Echocardiology：distinct region of disordered contraction, LV function, detection complication 5.laboratory examination: blood routine serum cardiac markers,STEMI,Laboratory,第九十八頁，共一百一十五頁。,Cardiac markers,* Most sensitive and specific marker of myocardial damage,STEMI,Laboratory,第九十九頁，共一百一十五頁。,Differential diagnosis 1.angina pectoris：chest pain, complication, general symptoms, elevation of cardia markers, ECG changes 2.acute pericarditis：characteristics of chest pain, time course of chest pain and fever, ECG changes 3.acute pulmonary embolization: chest pain, hemoptysis, dyspnea, increased load of RV (SIQIII),STEMI,Diagnosis,第一百頁，共一百一十五頁。,4.Acute abdominal symptom：acute pancreatitis, cholecystitis, cholelithiasis 5.aortic dissection：sever chest pain with (tearinglike), radiated to back，with aortic regurgitation, CT、UCG、MRI、chest Xray,Differential diagnosis,STEMI,Diagnosis,第一百零一頁，共一百一十五頁。,Before admission: tranfer, make diagnosis within 1020min, initiate reperfusion therapy as soon as possible Monitoring and general treatment: CCU Reperfusion Management of complication others,STEMI,treatment,第一百零二頁，共一百一十五頁。,1.CCU: hemodynamic monitoring, oxygen 2.Pain 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,第一百零三頁，共一百一十五頁。,4.anticoagulation: antithrombin, heparin, LMWH 5.limitation 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)：1000.0001500,000 U，iv fusion in 30min give heprin after intravenous thrombolysis therapy Primary Percutaneous Coronary Intervention(PCI) CABG,STEMI,treatment,第一百零四頁，共一百一十五頁。,AMI,PTCA,Stenting,STEMI,treatment,Primary stenting,第一百零五頁，共一百一十五頁。,Criteria for thrombolysis in STEMI,indication： 1.Chest pain: consistent with AMI 2.ECG changes: ST elevation 0.2mV in at least two contiguous leads。 new or presumably new LBBB 3.Time from onset of symptoms 12hrs：diminishing benefits but may still be useful in selected patinets 4.age 70yrs?,第一百零六頁，共一百一十五頁。,Absolute contraindication： 1.active internal bleeding (excluding menses) 2. Suspected aortic dissection 3. Recent head trauma or known intracranial neoplasm 4.History of cerebrovascular accident, known to be hemorrhagic，or ischemic attack within 6 months (including TIA) 5.Major surgery or trauma within 2 weeks 6.shock, no response to the treatment . 7.pregnant, SBE, suspected atrial thrombosis,Criteria for thrombolysis in STEMI,第一百零七頁，共一百一十五頁。,Relative contraindication： 1.BP180/110mmHg on at least two reading 2. History of chronic, severe hypertension with or without drug therapy 3.active peptic ulcer 4. History of cerebrovascular accident 5.Known bleeding diathesis or current use of anticoagulants 6.Prolonged or traumatic cardiopulmonary resuscitation 7.Diabetic hemorrhage retinopathy or other hemorrhage ophthalmic condition 8.prior 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,第一百零八頁，共一百一十五頁。,Judgement of the patency Direct：coronary angiography TIMI flow grade 23 Indirect： Return of the elevated ST 50% within 2hrs Relief of chest pain within 2hrs； 3. Reperfusion arrhythmias, within 2hrs：premature ventricular rhythm, accelrated idioventricular rhythm, nonsustained ventricular tachycardia, transient bradycardia, AV block 4.peak serum cardiac enzyme occurred early, within 14 hrs,thrombolysis in STEMI,第一百零九頁，共一百一十五頁。,Management of complication 1.arrhythmia Ventricular tachycardia：iv lidocaine, amidarone, betablocker VF：defibrillation bradycardia：atropin, temporary pace maker 2.shock：IABP 3.heart failure：no use of digitalis within 24hrs Special consideration: RV MI with hypotension,STEMI,treatment,第一百一十頁，共一百一十五頁。,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,第一百一十一頁，共一百一十五頁。,ACEI：reduce remodelling, increase mortality, and statins: stablize the plaque, improve endothelial function. polarized solution (potassium, magnesium） Others: vitamine, FDP,Routine use of calcium antagonist increase the risk of death in AMI patients,STEMI,treatment,第一百一十二頁，共一百一十五頁。,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 composed 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 either by fibrinolysis or primary PCI is the mainstay of therapy of STEMI,第一百一十三頁，共一百一十五頁。,Thank you,第一百一十四頁，共一百一十五頁。,內(nèi)容(n232。ir243。ng)總結(jié),Atherosclerosis。Responsetoinjury。Angiographic thrombus 01% 75% 90%。Increased FPA/TAT 05% 6080% 8090%。Activated platelets 05% 7080% 8090%。mortality 12% 38% 615%。Thank you,第一百一十五頁，共一百一十