Acute Myocardial Infarction Setting Priorities for Effectiveness Research (1990) / Chapter Skim
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The Knowledge Base for Clinical Issues in Acute Myocardial Infarction
The Knowledge Base for Clinical Issues in Acute Myocardial Infarction
Pages 9-24
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From page 9... ...
They include diagnosis and management of myocardial infarction in five phases: prehospital, emergency room, coronary care unit, hospital, and posthospital. Other issues centered on treatment options whether pharmacologic, invasive, or surgical—during the acute hospital phase.
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From page 10... ...
In some cases the reduced blood flow is caused by a blood vessel problem other than a thrombus. The underlying cause of most AMIs is atherosclerotic coronary artery disease, which causes progressive obstruction of the arteries in the heart, beginning in early adult life.
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From page 11... ...
Before an AMI, patients may have been severely restricted by chest pain or seriously debilitated by complications of previous episodes; alternatively, they may have been entirely free of symptoms, or they may have had a previous AW without complication. For many, life after an AMI is uneventful; others suffer major complications, including heart failure, angina, recurrent infarction, arrhythmias (heart rhy hm disturbances)
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From page 12... ...
Thus, identifying patients with possible AMI as early as possible in the community, getting them to emergency medical care, and continuing their diagnostic evaluation and subsequent treatment in a coronary care unit (CCU) have been major contributors to the almost 40-percent decrease in mortality from AMI over the last 20 years.
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From page 13... ...
Additional delay can occur at the hospital if emergency room medical and nursing personnel do not have well-defined protocols to assess patients rapidly and identify those subsets appropriate for specific treatments. With earlier recognition by the patient of Me potential seriousness of symptoms, state-of-the-art EMS intervention can effectively extend the capabilities of the hospital into the community, for example by routinely iniiiating thrombolytic treannent of appropriate patients in their homes or during transport.
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From page 14... ...
Other diagnostic tests have not proved as useful in diagnosing AMI in the ER. Creatine kinase, an enzyme released by damaged heart muscle, is very helpful in establishing the diagnosis of AMI over 12 to 24 hours, but it has not proved valuable in the early ER diagnosis because up to one-half of AMI patients will have normal values on a blood sample taken in the emergency room.
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From page 15... ...
Length of stay in CCUs or ICUs for AMI patients has progressively shortened over the 25 years that these units have been in use. This has resulted from the recognition and stratification of risk of complications, the development of continued monitoring in less intensive care units (so-called step-down or intermediate care units)
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From page 16... ...
An excellent method of risk stratification is "submaximal" exercise testing alone or with myocardial perfusion imaging with T1-201 (a picture of blood flow to the heart muscle)
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From page 17... ...
routine office tests, such as ECG, echocardiography, and serum lipids, to follow changes in myocardial ischemia and risk factors; (2) exercise testing, to measure residual myocardial ischemia; (3)
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From page 18... ...
Patients who continue to have chest pain, demonstrate myocardial ischemia on exercise testing, or give evidence of heart failure after AMI by the need for medication, cardiomegaly, or restricted activity due to shortness of breath or fatigue are often considered candidates for invasive diagnostic studies. In some cases, they may be candidates for revascularization procedures.
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From page 19... ...
Pharmacologic Therapy Choosing appropriate pharmacologic therapies is predicated on many different clinical factors, including the extent of damage to the heart muscle, recurrence of symptoms, coexisting conditions, and complications of the AMI. These factors can interact in many ways, making the clinical decisions even more complex.
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From page 20... ...
and narcotics may be used for appropriate indications, such as chest pain or congestive heart failure. Patients with recurring symptoms including specific ECG changes (ST elevation)
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From page 21... ...
The only medications shown to reduce short-term mortality in Group 1 AMI patients are thrombolytic agents, aspirin, and early beta blockers. Thrombolytic agents should be administered within one to two hours after the onset of symptoms, if possible, but some benefit extends to as long as 24 hours after the onset of symptoms.
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From page 22... ...
Rehabilitation Rehabilitative care after myocardial infarction should help restore the patient to the pre-illness lifestyle and level of function. It should, additionally, favorably modify conventional coronary risk factors, limit psychosocial disability, and reduce the increased complications of immobility in the elderly.
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From page 23... ...
Teaching elderly patients how to simplify work and consene energy can further extend the duration of independent living for coronary patients win limited residual function. By age 80, as many women as men have AMIs.
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From page 24... ...
The challenge to the clinical community is to deliver these rehabilitative services in a cost-effective manner.
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